One of the industry experts I learn from every time we speak is Ginny Kenyon, principal at Kenyon Home Care Consulting. Ginny helps open home care agencies and has given Ankota great inputs on our software. We at Ankota strongly believe that keeping elderly people healthy and comfortable in their homes (and out of the hospital) is an important step in the evolution of healthcare. Ginny is one of the pioneers driving moves in home health delivery. Enjoy her post (below).
For years I have dreamed of a day when home health nurses and therapists would be in charge of their own services. Doctors would be a part of the team but not the “directors” of the care plan. To me, it has never made sense that a physician who knows little about home health services is required to sign off on all orders.
I agree physicians or nurse practitioners must confirm the working diagnosis and the medications. But in home health the professional clinician completes the assessment, defines problems in terms of their discipline and establishes the care plan, not the physician. A physician directing the home health plan of care makes as much sense as asking a plumber to sign off on and be in charge of the electrician, the sheet rocker, and the roofer when building a house. Physicians have repeatedly objected to this requirement and now with the addition of face to face documentation, their objections are even more stringent.
Current Care Plan Paradigm
So how did we get here? When and why is there a paradigm that the physician directs the care plan for other providers? Therapists have individual practices not requiring physician oversight, but not nurses. The origins of physician control over nursing practice started in the early part of the last century. It was determined that the independent practice of nurses was the single biggest threat to the financial future of physicians. As a result, the American Medical Association succeed in getting congress to pass legislation requiring nurses to work under the direction of a physician. Unfortunately for nurses, doctors, consumers and payers, this has not always been the best practice.
Many physicians signing the care plan developed by clinicians tell us the plans make little sense to them. They sign what is required so patients can get the care they need. Is it any wonder the plans make no sense to them? They aren’t medical plans of care, but nursing and therapy plans written in the language of each discipline. Is it time for a change? My idea is for physicians to continue to sign the medical components – the diagnosis, medications, and required diagnostic tests – while disciplines write specific plans which are signed by individual disciplines.
Think of the money spent trying to support this false paradigm! Think of all the hours spent by home health staff gathering a physician signature on the 485 and verbal orders. Think of the patients denied services because physician didn’t want to be deal with the paperwork burden required for home health services.
Future Care Plan Paradigm
So what could the future look like? I dream of a home health future where physicians are part of the team and work with other disciplines to achieve desired patient identified goals. Each discipline is responsible for their part of the care plan and nursing is responsible for coordinating the overall plan. Long ago, Medicare recognized home health nurses as the patient coordinator or case manager negating a change in current practice.
The physician confirms the working diagnosis and medications electronically and each discipline signs and dates their plans. Compliance with the home health conditions of participation would continue to be the home health clinician’s responsibility. In my new world, the requirement that the physician certify home bound status will go away.
Homebound Rules Need to Change
If the intent of physicians certifying homebound status was to prevent fraud, it has not been successful. The clinician in the home doing the assessment is the best person to determine homebound status. However there is second serious issue with the homebound rule. It interferes with the ability to provide the care needed to return clients to full capacity and independence.
Much of home health’s role is assisting patients to make lifestyle changes, stabilize their condition and prevent further exacerbations which may lead to more expensive care. To achieve these goals, particularly for those with chronic diseases and co-morbidities, time is needed beyond a 60 day episode. But, because of the homebound requirement, the patient is just beginning their needed changes when they are discharged. Evidence and experience proves it takes as long as 6 months to successfully integrate a lifestyle change. We are finally seeing a glimmer of hope as CMS begins to recognize that those with chronic diseases need longer periods of care and support beyond the current homebound phase.
Also, the 485 must be revised to reflect these new changes. Numerous physicians have complained for years that the 485 makes no sense and provides little useful information. Physicians are asking for patient progress information, response to provided services and any identified medical issues that need their attention. These are not unreasonable requests and as team members are our responsibility to provide. However, this will require a paradigm shift for home health clinicians.
A New Care Plan Dream
I believe returning to an individualized plan of care structured in care plan format is the goal to strive for. Not only will this help the team plan better, but will help those new to home health better understand the care planning process. The current system does not support critical thinking skills and the entire process has become an exercise in checking off boxes.
The system is starting to change from rules of enforcement to becoming outcome focused. This change must emphasize the importance of patients achieving desired goals and outcomes as well as care cost reductions. I believe with these changes, costs will decrease and outcomes improve as well as physician, clinician and patient satisfaction.
It’s time to dream a new dream! These are just a few ideas I see the home health industry needing to achieve true patient centered care. This will allow each team member to fully use their skill set to assist patients in goal achievement. What are your dreams for the future of home health? Contact Ginny Kenyon at Kenyon HomeCare Consulting to discuss or leave a comment below. Together we make a difference!
This article, A NEW DREAM FIR THE HOME HEALTH CARE PLAN first appeared in Kenyon HomeCare Consulting blog.
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