Take this patient NOW! Avoid the pitfalls of hospital-affiliated referrals
Education and communication reduce inappropriate referrals
(Editor’s note: Due to the delicate nature of some of the information in this article, many of the sources quoted agreed to share their comments only on the condition of anonymity.)
"You have to take this referral." How many times have your admissions staff heard this line? Unfortunately, they most often hear it late on a Friday afternoon and in connection with a referral that they know or suspect is inappropriate for home care referral. How do your staff handle this situation when the referral source is the hospital with which you are affiliated?
"Whether the pressure is overtly exerted or the agency has merely perceived the pressure, the sense of obligation is real," says the director of a home care agency in an urban setting. "Sometimes, in an effort to emphasize the urgency of the referral, the discharge planner will tell us that no other agency will take the case," he adds.
This type of comment underscores the fact that the case may be an inappropriate home care referral, but the hospital-affiliated agency is expected to take the referral in spite of that fact, the director adds.
"Many agencies have long-standing problems with inappropriate referrals from their hospital owners or affiliates," says Elizabeth E. Hogue, Esq., a home care attorney based in Burtonsville, MD.
"The problem originated in the cost-based reimbursement rules under which hospitals operated prior to the prospective payment system (PPS). A hospital could reduce length of stay by referring the patient to home care and shift the costs to the home health cost report," she says.
Because hospital administrators believed that the organization would never make money on home health, the extra loss in revenue on the home health side of the business was not important, Hogue adds. Now, under PPS, home health agencies should be making a profit, so cost shifting does have a significant effect on the overall business, she says.
"Even when we are given inappropriate referrals, I am responsible for generating a positive financial picture to our chief financial officer," points out the manager of a Midwest home health agency.
While the financial aspect of inappropriate referrals raises concern among home health managers, the most important issues related to inappropriate referrals are ethical and risk management, Hogue says. "It is not ethical to refer a patient to inappropriate care, and it is very risky for a home care agency to accept a patient who requires care it cannot provide," she explains. (For more information on liability, see Hospital Home Health, February 2003, p. 21.)
While some inappropriate referrals may occur because it is easier to send a patient to a home care agency than to a long-term or subacute care facility, more often, the cause of the inappropriate referral may be a lack of understanding on the discharge planner’s part, Hogue says.
"The most significant problem we see with inappropriate referrals is the lack of a willing or able caregiver," says the Midwest home health manager. "The discharge planner is told to get the patient out of the hospital, and the family says that there is someone to care for the patient with home health assistance," she says. "What the discharge planner may not understand or explain clearly to the patient’s family is that home health visits are intermittent, and if a patient requires help with daily activities, a caregiver must be with the patient more than once a day for an hour at a time," she says.
Referral sources don’t always assess the caregiver either. In one case, the home health nurse arrived at the home to find that the "willing and able caregiver" — who the discharge planner said was available — was an elderly, demented wife who was expected to care for her elderly husband with an ostomy and IV fluids, points out the Midwest agency manager. "In this instance, the home health nurse arranged an emergency transport back to the hospital," she says.
"We also have discharge planners who assume home health nurses will do all of the patient and family education, but we expect some teaching to occur before the patient is discharged," says the Midwest agency manager. "We have had this problem so many times that when we get a diabetic patient referred to us, we see him or her immediately because we don’t assume that the patient has received any teaching," she says.
The need to communicate
Another problem is a lack of communication, says the Midwest manager. "We don’t always know what medications the patient should be taking or even if they filled their prescription prior to discharge," she says.
"Discharge instructions might simply instruct the patient to continue on medications, but don’t specify what medications," the manager explains.
Many times, a home health nurse arrives at the home of a rural patient to find that the patient and family are unclear about what medications to take and may not be able to fill the prescription easily in their area, she adds.
The best way to address many of these problems is to improve communication between the referral sources and the home health agency, Hogue points out. "Use specific examples of inappropriate referrals to educate discharge planners and administrative representatives about the problem," she suggests.
"Because many hospital administrators don’t always think that home health can make money, don’t focus on the financial aspects of inappropriate care but do focus on risk management issues," Hogue says.
Caring for a patient who requires more intense care than home health can provide or sending home health employees into potentially dangerous environments increases the liability risk for the hospital as well as the home health agency, she adds.
To improve communications with one hospital within the health system that typically made inappropriate referrals, the Midwest agency manager changed the referral process from the use of faxed referrals to telephone referrals only.
"Now, we can ask questions and probe more deeply when the referral is coming from someone who has made inappropriate referrals in the past," she says. "We make sure we ask questions about medications, the caregiver’s mental and health status, the environment, and even the physician making the referral," she says.
This last item was added when her staff discovered that medical residents rather than the supervising physicians were making the decisions to discharge the patient to home care, the manager explains.
There are ways to address the problem, says the manager of a Northern home health agency. "We used to have a problem with the hospital wanting to send inappropriate referrals to us, but we haven’t had the problem in a few years," she says.
The secret to her agency’s success in this area is the organizational structure of the hospital. "My boss is also the boss of the discharge planning department," she points out. Not only does this give both departments an advocate on the management team, but also it guarantees a free flow of information between the two departments, the manager adds.
"Because he sees both the discharge planning and the home health sides of the issue, he is a strong advocate for appropriate referrals with other departments and the medical staff," the Northern agency manager says. Even without a formal reporting system, a home health manager can seek out an advocate within the hospital management team, she suggests.
If you’re not lucky enough to have an organizational structure that supports you, be sure you have a clearly defined appropriate admission policy for your agency, the Midwest manager suggests. Make sure your primary referral sources know about the policy and offer to present inservices on appropriate referrals. "The best education, however, is a one-on-one discussion of a specific case with the referral source, which might be the discharge planner as well as the physician," she adds.
Also, know how you will respond to inappropriate referrals, suggests the manager of the urban agency. "If we determine that the patient is not eligible for Medicare, we offer to take the patient on a private-duty basis," she says.
"Then, it’s up to the hospital to determine how payment will be made, or if we should take the case on a charity basis," the manager adds.
The more collaboratively you can approach the referral of patients who may not be appropriate for Medicare home health care, the better the situation for everyone, says the manager of the urban home health agency.
While everyone in the referral process feels
the everyday stress of working in health care, he points out, "We need to put the patient’s needs first and do our best to deal with their needs."
[For more information about inappropriate referrals, contact:
- Elizabeth E. Hogue, Esq., 15118 Liberty Grove, Burtonsville, MD 20866. Telephone: (301) 421-0143. Fax: (301) 421-1699. E-mail: [email protected].]
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