skilled home care referrals

Presentation by

Graciela Lange

Copyright March 2011

• Nursing• Physical therapy• Occupational therapy• Speech therapy• Social work

Skilled Home Care: In home services provided by qualified personnel:

What do these disciplines provide?

• Clinical assessment• Treatment planning• Treatment provision• Patient and/or family education• Health status monitoring• Reassessment, referral, and follow-up

Home care agencies will not accept

• Patients unwilling to participate in home plan of care (non compliant or refuse care).

• Patients without an address or phone number• Patients w/ hx active drug use - violence • Patients whose scope of care exceeds what

VNS can safely provide and support.

Nursing

• Medication management• Disease management (symptom management

etc.)• Access line care e.g. PICC • Patient/caregiver education related to disease

process • Wound care • Labs related to referral diagnosis

Occupational Therapist

• Functional assessment ADLs and iADLs• Evaluation for adaptive equipment• Evaluation for home safety modification• Patient/caregiver teaching related to

equipment etc.

Physical Therapist

• Strengthening- conditioning • Range of motion • Gait-mobility training (balance, transfers) • Evaluation of assistive mobility aids • Home safety evaluation • In-home rehab

Speech Therapist

• Cognitive evaluation• Speech rehab • Dysphagia evaluation

Medical Social Worker

• Patient-caregiver support• Assist w/ fiscal – community resources• Stress management• Grief support • Long range care planning

Goal:

• To support in restoring, improving their health status and maintaining their independence

• Provide short term intermittent skilled care• Individual disciplines (not interdisciplinary • RN or PT or ST is identified case manager• OT and MSW can’t open a referral – Agencies are state-licensed or– CMS-certified for the level of care provided (SHC,

H/HHA), – Must be in good standing with the state.

Home Care Agencies

Home Care Agencies

• Agencies have catchment areas• Not all agencies offer same disciplines e.g.

speech• Not all agencies offer same services e.g.

Wound care specialist or falls prevention program

• Some agencies have better outcomes with specific skilled needs (Refer to OASIS Medicare data – Medicare website (compare home health agencies)

• Some agencies provide earlier start of care dates • Not all offer weekend home visits for routine care • Patient preference should be considered when

selecting the home care agency

Quality Oversight – Monitoring

• Service quality complaints should be reviewed by referring agency –hospital.

• Create process for customer feedback• Report suspected neglect- abuse involving

caregiver, family etc. (mandated reporting)• Sustain and cultivate partnerships with home

care agencies - staff

Questions?

- Thank You

Graciela Lange | Presentation © 2011