Nursing Care Plans and Denials
One size does not fit most…..or any of our current patients
New survey rules took effect May 1, 2011, yet nursing everywhere continues to struggle to define progressive, meaningful care plans that are truly based on an assessment of the patient’s actual condition. Clinicians grasp tightly to easy care pathways that have been refined over time throughout the PPS era, or document interventions via check box protocols that address every patient in a certain category or diagnosis group. Pause for a moment and consider the following; it is rare that any two patients are similar, let alone identical. Yet, we continuously categorize them as such, deliver the care as such, and are then surprised and disappointed when survey results that reflect programming and clinical quality turn out less than favorably.
Considering this realty, it comes as no surprise that agencies across the nation are receiving audits, facing denials, loss of billing privileges or payments, and in all too many situations, garnishing the attention of Program Safeguard Contractors such as ZPICs (Zone Program Integrity Contractors). With therapy as the primary area of clinical concern regarding integrity in home care for quite some time now, the creation of nursing care plans that are OASIS based and individualized to the deficits and unique needs of the patient, have become a back-burner concern in many of our agencies. As a result, the clinical content of these aspects of our care programs have suffered, and this approach has now pushed this to the forefront of concern for many agencies. Furthermore, reform proposals for our industry, as well as the care models of the future (ACOs, Post-Acute Bundling, etc.), will require efficiencies in this aspect of our programming.
As CMS, Med Pac, and all auditing entities reform and ramp up their processes, nursing care plans, in many instances, have failed to evolve to keep pace with the elevated levels of scrutiny. As the industry forges forward toward ACOs and their inherent Care Transition requirements, efficiencies for savings, and producing clinical care with the highest of quality outcomes and the lowest of re hospitalization rates, will be the order of the day. Despite this, we see agencies over and over deliver nursing care plans for patients that state……
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Efficiency, productivity, and effective programming with management oversight are the only survival plan for the future. The past model of ineffective clinical delivery, free of focused and individualized care plans, is how Home Health Providers, and their nursing clinicians, will fail in the future. Too often clinicians defend their care plans by these simple rules…that’s how we always have done it. Health systems, seeking answers for the care questions of the future, will undoubtedly look to homecare for solutions. Programming philosophies, combined with financial limitations, will prevent any level of return to inpatient care delivery, and Home Health is the affordable option of choice.
But the reality that homecare is the affordable option will quicken the pace of clinical change required for participation and survival in the future. The value of and need for homecare will not disappear; but agencies that do not move forward in a progressive, rapid pace, continuing to produce fair to poor outcomes, and lacking clinical efficiency and management oversight, all coupled with high re hospitalization rates, will.
The HHSM Nursing Newsletter is written by Kimberly A. McCormick, RN/BSN, Administrator of Phoenix Home Care, of Burr Ridge, IL. Her expertise is based on sixteen years of homecare experience.
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