Control PPS costs with early discharge plans
Second in a two-part series
In Part 1 of this series on discharge planning in the April issue of Healthcare Quality Management, Lucy Lee, RN, BA, MHA, CHCE, owner of Lee Health Care in Hamilton, TX, explained how her agency, as part of a prospective payment system (PPS) demonstration project, has begun preparing for the imminent change. Her nursing staff have changed their focus to include discharge planning at the very beginning of care. Home health nurses talk to patients about independence, teach them about their illnesses, assess their abilities to care for themselves, and prepare family caregivers with specific goals and discharge dates in mind.
Teaching self-care
Lee says some problems that can interfere with the teaching process are hard to discern on a first visit. Those problems can include learning difficulties or plain stubbornness.
"We’ve got crotchety old German farmers who’ve been the boss all their lives, and by gum, no young chick is going to come into their house and tell them how to do things," Lee says. "In those cases, we know it’s going to be a harder process and we have to adjust what we’re going to teach."
The agency usually has more than one person seeing the patient, including different nurses, therapists, and aides. All can provide valuable perspectives in determining what might be an obstacle to care.
Lee Health Care also has a director of patient care who reviews every case, looking at factors that may have escaped front-line providers.
"She can look at it a little more objectively and can say, I don’t think this makes sense,’ or It looks like you’re going to have a problem with this situation.’ It’s just another set of eyes, another brain working on the process, and that has helped us a whole lot," Lee adds.
Social workers help find alternatives
At the VNA of Texas in Dallas, review is conducted as part of regular case conferences in which both new and continuing patients are discussed, says Emily Tripp, RN, MED, CHCE, group vice president for home care and hospice for the VNA.
"The new patient’s care plan is reviewed at the case conference and it includes the discussion of what the discharge plans are for this patient, the progress the patient is making toward meeting those plans and any kind of impediments to it," Tripp says. "And then the team will [decide how] they need to do to help the patient with those problems."
In cases where patients are found to need more than self-care or family assistance, the VNA involves a social worker, who can help with referrals to other community resources.
"We try to find someone else who can assume some of that care — family members or neighbors or sometimes church members," she says. "Some-times there are more formalized groups we can access in the city."
Social workers can help plan discharge
But in the most difficult cases, where a patient simply cannot remain at home, social workers can help plan the discharge to institutional care.
If a patient refuses to accept the alternatives, and the agency has done all it can under Medicare, then the patient is informed via an advanced beneficiary notice that the care he or she requires doesn’t qualify for Medicare coverage. Patients are given the option of paying for the care themselves or making other arrangements.
Tripp says that at the VNA, those situations are handled in a conference-type setting that includes the agency, physician, patient, and family members.
"We make sure we’ve covered all the options as far as what we can do for the patient," she says. "We explain the process, and what the situation is, so we’re not in a position of abandonment. Someone may feel like we’ve abandoned them, but that’s not the same as giving them options for where they can get the care. If they choose to refuse to access those options, then that’s their choice, but we can’t just always jump in and be that option forever."
Both Lee and Tripp say it’s vital at the point of admission to determine whether home care is the right option for a patient.
Tripp says the criteria for admission include the requirement that care can be administered safely at home. "We’ve had referrals for patients who really needed an institutional kind of setting, continuous care around the clock."
In those cases, she says the agency goes back to the referral source to determine to a more appropriate care setting.
Lee says the years of practice her nurses have received through the PPS demonstration have helped them improve their skills at assessing and teaching patients."Before, if [the patients] didn’t know how to read a thermometer, we could go several times and teach them," she says. "Well, we’ve learned how to do that better now, because we are more concerned with how much resource utilization we have."
They also are better at seeing the big picture of care — how caregivers and other factors affect the patient’s progress. For example, instead of training new caregivers one at a time, a nurse would determine at the beginning anyone who might need to know caregiving skills and teaches them all at once.
Overall, Lee says, the increased emphasis on more efficient care has put more emphasis on patient independence. "We’ve all spoken those words for the 10 or 15 or 20 years we’ve been in home health; but in the last two years, we’ve had to change our thinking and really mean those words, that we want to move toward patient independence."
• Lucy Lee, Lee Health Care Inc., 114 E. Main St., Hamilton, TX 76531. Telephone: (254) 386-8971. Fax: (254) 386-5040. E-mail: [email protected].
• Emily Tripp, Group Vice President for Home Care and Hospice, Visiting Nurse Association of Texas, 1440 W. Mockingbird Lane, Suite 500, Dallas, TX 75247. Tele-phone: (214) 689-0077.
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