Nursing Now!
Many agencies have recently experienced unexpected deficiencies regarding the quality of nursing services in the agency. Why?
The Department of Health surveyors expect that nurses will practice under prevailing professional standards. This means adopting assessment practices that will help manage emergent and chronic illnesses.
Examples of simple, old and effective nursing 
directives to manage chronic illnesses include:
- Directing staff members caring for clients using anti coagulant therapies to report bruising, bleeding, falls, etc.
- Directing staff assigned to the congestive heart failure patient to measure body weight and record and report weight gains.
- Requiring observation and reporting of changes in nail bed color in patients being treated for chronic respiratory conditions.
While these types of directives are commonly written on the patient plan of care, these tasks must be added to the aide care plan to assure consistent observations and reporting so necessary for the management of chronic illness.
Expectations of nursing management of home care clients are rising! The Department of Health expects nurses to manage home care clients as though the agency nurse is the primary professional manager of the client....even when our agency nurses are NOT the primary nurse caring for the client.
For instance, on a recent survey, a surveyor noted that the diabetic patient was not testing blood sugars on a daily basis with a home blood sugar monitor. The physician had ordered once per week blood sugar testing by the patient. Are nurses in home care practice expected to direct the patient to test blood sugars more frequently than the physician ordered? Are nurses supposed to request a physician's order for more frequent testing? These are the emerging questions.
In fact, the Department of Health expects nurses to ask the question! "Could more frequent blood sugar monitoring assist the patient to improve blood sugar control? If so, there are home care aides who could report abnormal blood sugars to the agency RNs for action."
In the licensed home care services agency, many clients are served under contract with another care providing organization. These contractual agreements must be very clear regarding which organization is providing nursing services to the client.
Which agency is performing supervision services under the contract? Are the nurses performing supervision visits expected to perform client assessments during supervision visits and then contact the primary nurse with concerns? Should the review of the patient care plan for appropriateness to the client's needs include detailed nursing assessment of the patient?
These are questions that licensed home care services agency struggle to answer. The answers are often different with each contractor; even when agencies work under similar contracts with different organizations. How shall agencies determine what is appropriate practice for supervising nurses? Set the nursing bar high!
Patients who are served directly by the agency should receive professional nursing management for any identified health problems. This has long been the expectation of the Department of Health for licensed agencies. The agency RN should treat the patient as if the agency is the primary care provider.
So the private pay client who hired your agency to assist with personal care due to functional deficits...
- Must have a complete nursing assessment including identification of new and chronic problems.
- Must have physician's orders appropriate to manage new and chronic problems.
- The nurse must write a nursing care plan identifying and strategizing care, define reassessment frequency and goals to manage problems.
- The aide care plan must include observations and reports of identified important observations and activities involved in managing the clients' needs.
- The aide must be trained and instructed in making observations, reporting and recording.
- The RN must use the nursing process to plan, execute, reassess, change the plan of care and report to the physician.
Significant changes involve caring for clients who are also served by other organizations who retain primary nursing responsibility.
This is where the dreaded "follow-up" befalls LHCSA nurses. LHCSA nurses who discover problems with the client under contract are still required to call and report the problem to the primary nursing organization. This is often easier said than done.
The LHCSA nurse must be assured that the primary nursing organization has received and acknowledged the communication AND that the problem is being managed.
Certainly, electronic communication is the most efficient and often most effective method of communication. The LHCSA must retain a record of all such reports and communications to ensure that the agency has proof of reporting and assurance that the client's problem is being addressed.
As home care agencies slide into the future of home health care, communication will be the biggest key to cost effective successful outcomes. Payers will expect LHCSAs to perform more services, provide more information, track and analyze data and to do so without added cost! Successfully move into the future of professional practice in home care nursing!
- Review RN assessment and reporting work processes to ensure needed information is collected and reported.
- Establish effective, efficient communications regarding clients with other parties involved.
- Provide important professional observation and assessment information quickly and consistently to appropriate parties.
- Track, record and review changes to ensure management of problems by prevailing professional standards.
Remember when LHCSAs were the "vendor" and we were just supposed to provide the aide and stay out of the client's professional health care management?
Well, the successful future of home care may depend upon the LHCSA nursing assessment information getting to the right parties in a fast and efficient manner.
Why should taxpayers continue to pay for the LHCSA to perform the client assessment upon a supervision visit and then the contracting agency to perform another upon receipt of the LHCSA nurse's report?
These past payer practices cannot be sustained into the future...they are repetitious, and expensive. Gear up for the future! Be the agency with the most information, at the best time, in the most cost effective manner.
Karen Murphy, president of Adept Resources in Albany, NY is a highly sought after home health care consultant and a frequent partner of HHA eXchange. 
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