Tuesday, May 5, 2015

A quick answer to an often asked question

When speaking at public events and often while engaging on social media, I end my health care discussions with the phrase, "you come too". In recent years others have noticed my use of the phrase and have started to question the true meaning behind it. Well my savvy surveyors of speech, the phrase does have a definite meaning to me.

I see health care reform and all that has been born out of reform efforts as an adventure. Often while researching one topic, another interesting or disruptive approach is found. How wonderful is that? That said, I believe we all have a responsibility to share our adventures. 
Robert Frost

One of my very favorite poets is Robert Frost. I love how his simplistic approach to subjects expose a deeper thought process and deeper feelings. One of my favorite Frost poems is, The Pasture. In its simplest interpretation, the poem is about the writer performing everyday tasks and inviting a friend to tag along. However, if you dissect the poem further, its about the writer going on a journey and discovering other untold possibilities, thus inviting the stranger to come along . . ., "you come too".  This is the way I view health care. For me it is an everyday journey, replete with other unspoken possibilities to disrupt and discover  in this business we call health. Inviting others to discuss, debate, or research health care issues with me, I believe, offers greater opportunities to learn and improve the world in which we live.
So there you have it, my use of the phrase, "you come too" is spoken in all sincerity with the hope that others will find the study of health care and health care technologies as exciting and curious a journey as I do. With that I will get back to it now, discovering, learning, developing what I hope will be the next big thing to improve our nations health. You come too!

Monday, May 4, 2015

Defensive Discharge: Comprehensive Planning for the Inevitable Discharge

image courtesy of  StockImages +FreeDigitalPhotos.net 
About a month after I launched my policy business a provider approached me with a problem, a state Medicaid program had cited the agency for improper discharges. The provider asked how a discharge should be handled. I asked what the agency's current policy stated, to which the provider answered, "what policy?"

This is the time of year when all savvy providers are seeing impressive growth, "our own holiday season," I always say. However, with the increase in admissions comes also the realization that you'll be losing a patient or two . . ., or three. This isn't usually  because of anything you're doing wrong; it's usually because you're doing something completely right. Unavoidable discharges or "shrink" as we've coined it is the result of a patient reaching his/her goals and the primary physician ordering a decrease in home care services. This happens primarily in the pediatric home care arena but may also happen with other segments of the population. For example, when a patient has been treated for a wound over an extended period of time and then the wound heals, the agency will receive instruction to discharge. For the sake of this article lets concentrate on the seasonal discharge, those that will occur during the same period admissions are expected to rise.

What exactly is a "seasonal discharge?" A seasonal discharge is unique to the home care environment. It occurs during the same three months (March - May) as those when we normally see increased home care admissions.

Why do these discharges occur? Seasonal discharges occur simply because flu season or the threat of high rates of infections are lessened.

Who orders the discharge? More times than not a physician will order a discharge from home care because a patient has met all goals, has been decannulated, or no longer requires an awake/alert care giver to monitor for signs/symptoms of an infection. Just to clarify, awake/alert means overnight, and is not meant to imply its okay for home care staff to sleep on a shift. I always get that question . . ., hmm. 
What happens if the agency doesn't agree that the patient is ready to be discharged? If an agency, against a physician's decision, decides a patient is not ready for discharge, they'd better have a really good and documented reason. Rarely will an insurer side with an agency when a physician has ordered the discharge of a patient.  A request to continue services must be carefully documented and presented in a way that protects the patient's health, not the agency's interests. One notable exception, when a patient has multi-discipline care and clinicians have not been sharing information; one physician may order a discharge, while another physician may want care continued. This is why care coordination is so important. All disciplines involved in a patient's care need to have all pertinent information to make informed decisions about care. That said, once a discharge has been ordered, the agency still has responsibility to the patient to wean down care.

What is a wean down for discharge? Just as we wean admissions, discharges should also be weened. For example, if the discharge is to occur within three weeks (post decannulation), hours of care should be decreased gradually over that three week period. The agency should discuss the schedule with the primary physician, the patient, and the patient's family where applicable.

How do we document the discharge? the agency should have a comprehensive discharge policy. The policy should be reviewed annually and as needed where unique discharges arise. The agency should also have an official discharge form, which is used by the supervising RN to discharge clients. 

Seasonal discharges are just one kind of discharge. If you've been following me for a while, you're aware of the many discharge situations. Remember, regardless of type of discharge, it must be documented. You must also have a policy for removing records from patients' homes post discharge, even if returning to the home is not an option. Also, most insurers have a specific period for which you must maintain discharge paperwork. If not, the agency should have their own policy. 

Where can I find more information on discharge policies? Call me, write me, or join me in a Twitter chat. You can also call your payers for information on their discharge policies. 

Hey savvy provider, would you like a complimentary discharge form? Follow me on Twitter @AuthorShereesem and send me a direct message. I'll email an editable form to you.