Technology killed the Home Health Plan of Care

When I started working with technology in 1999, I envisioned that technology could and would make a mediocre nurse great.

Imagine my chagrin, now 15 years later when the opposite has happened.  Now, once terrific clinicians have outsourced their skilled training and blindly check boxes, check lots of boxes and produced a generic care plan that can be found all over the country. So generic in fact, that the reason for admission to home health can rarely be distinguished.

I have attached a black and white powerpoint (created for easy printing) on a training that I’ve done which include what the regulations have to say about orders, specificity or orders and documentation that supports medical necessity.

One thing that I would add here is that a good home health plan of care begins with goals. It is one thing to say that the patient will stay out of the hospital, have no falls, vital signs within normal limits, verbalize understanding of disease process and medication regimen, etc. However those are goals for everyone. Heck, those are MY goals!

Your goals for everyone is kind of a mission statement, “keep patients out of the hospital” and “demonstrate independence in disease management” If you start the thought process for goals with “demonstrates independence in disease management as evidenced by……. the goals kind of write themselves

Goals are important as they force us to focus on the disease and conditions that precipitated the admission, but good goals on the plan of care make that qv requirement of document progress toward goals much easier.

Consider a goal for blood sugar, blood pressure, TUG, pain, etc. I’m not talking about the parameters, which are written to tell us when we need to get the physician involved in making changes to this care plan. But actual targets. Don’t be afraid to put a target glucose, BP reading, pain scale report in the goals. Then when you are charting your visit, think is the patient progressing or not progressing toward those targets.

Wait, that’s not enough Medicare/CHAP/JCAHO won’t accept “continue poc”, “fair”, “30%, etc . so take it one step farther. “progressing as evidenced by………..list the evidence[ BS have remained between 70 and 120 for 3 consecutive weeks]“  and it is quite acceptable to say “NOT progressing as evidence by….did not record daily weights 2 days of the past week]

Now that we’ve got some good, specific goals,  we can back into the interventions. What interventions are going to be required to meet these very specific goals? What do you have to teach a new or exacerbated diabetic to do to become independent in their disease management?  (daily blood sugars, keep a log, sharps, standard precautions, foot exam, sick days, insulin admin, etc. Then you do it. Consider, f you’re going to teach all those things; is once a week for 9 weeks a good frequency to accomplish that education, allow for demonstration, and a period of maintenance? Probably not.

Truth be told, once a week for 9 weeks is rarely a clinical decision. There is really nothing that requires a skilled nurse visit once per week for 9 weeks. It is popular for a number of reasons, 1. its easy to schedule, and  2. less than 10 visits per episode is a good financial position.

A better frequency might be 3w1 (to do all that teaching you need to do) and 2w2 to assess if the patient is doing the things you’ve taught them to do; i.e, return demonstration or verbalization) and then 1w6, or even every other week for 6 weeks to ensure that what you taught them and what they demonstrated in return is actually impacting the goals (remember the goals?) That is still 10-13 visits.

I implore all the software vendors out there to reconsider the way that the orders and interventions (locator 21 and 22) get populated from the assessment.

P.S. It would also be helpful if the plan of care populated the visit note, so that the nurse could chart the interventions that were completed, goals that were met, and reports can be run to determine when the care plan hasn’t been followed. Misys had that in 1999, what happened to that idea?

Home Health 101 for clinicians

Feel free to use the presentation if you find it helpful. My gift to you.



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