Monday, December 8, 2008

Another aspect of the "hospitalist program model"

Home Health Care is another aspect of the problematic hospitalist program model.

Remember that an important aspect of the hospitalist program model is that each patient is assigned a "resource manager" at admission. This "resource manager" is supposed to provide the seamless transition from hospital care to post discharge care.

In apparent consultation with the "medical team," the "resource manager" determines whether the patient should be discharged:

(1) to home under self care;
(2) to home under home health care; or
(3) to nursing home (or other stage of assisted living).

As a patient's advocate, you better be right in the mix when the discharge decisions are being made. The resource manager tried to convince me (despite every neurological and psychological consult) that my dad suffered from dementia.

In a large sense, the Duke University Hospital resource manager took out her dislike of me on my father. She would have been delighted if my dad were in a nursing home. She did not like me because I was at the hospital everyday for my dad. I did not allow people to mistreat my dad.

The resource manager seemed to think that she could direct the course of my dad's life. I thought otherwise. I took the resource manager out of the loop and went directly to the physicians to determine the plan for my dad.

The hospitalist program plan takes the patient's autonomy completely out of the picture. The hospitalist works with the resource manager to dictate the discharge plans. Not in my world.

Every person reading this should know that they can (and should) communicate directly with the physician. Do not get sucked into letting the resource manager be the middle man between the doctor and the patient.

I get the sense that the resource manager is designed to allow the hospitalist to practice medicine without the annoying interference of the patient or his family.

The advantage to your being directly involved with the discharge is that then patient is more likely to have a successful recovery and recuperation. We all want to avoid re-hospitalizations on the same issue.

My dad was discharged "to home under home health care." He has a port-a-cath in his chest and he needs antibiotics infused in the port every 8 hours.

The infectious disease physicians wanted blood work weekly (to monitor the foot infection). So the "resource manager" suggested that my dad have "Duke Home Health Care" to change dad's port needle every week and draw blood.

The attending physician (orthopedic surgeon) wanted dad to have daily wound care on his "bad foot."

I wanted dad to return to physical therapy. Dad has worked with the most amazing Duke physical therapist (Dana Pierson) since he was first diagnosed with cancer in mid-2007. Dana is amazing. He helped dad through chemotherapy and all of the whack hospitalizations. Dad trusts Dana.

Problem: Mr. Pierson is an out-patient physical therapist. Home Health Care contemplates that the patient is home bound. Duke Home Health tried to convince me to dump Duke out-patient PT and have a home PT work with my dad.

Eventually Duke Home Health told me that Medicare would be suspicious if dad was doing out-patient PT and receiving home health care.

Yeah!!! A reason to dump home health care! Okay, actually, I "fired" home health care. I told the infectious disease and orthopedic physicians that someone would need to make appointments for dad to get blood drawn through the port because no one was going to poke his arm again. Period.

If your loved one has home health care then you better be a good advocate. It is absolutely unreasonable to expect that the home health care worker will be loving and careful (or even competent) simply because the care is taking place in a home environment.

(1) Duke Home Health Care never made appointments. They gave us a few hours notice. There was not even an understanding about what days of the week should be reserved for home health care.

It seemed to me that the home health care workers did not respect the patient's schedule. Okay. I get it. The patient is supposed to be home bound. By the home health care's disregard for the patient's time, I presume that most home health care patients live alone.

My dad lives with his wife (my mom) who owns her own business.

(2) Duke Home Health Care RNs did not know how to access a port-a-cath. One nurse had to teach my dad's nurse. Then, although they placed the new needle into dad's chest port, they were unable to obtain a blood draw on the port. Dad has had the port for over a year and every other nurse has been able to draw blood.

The RN poked at my dad's arm repeatedly to get a vein. She left dad with a horrible bruise on his arm and hand. My dad has infections. Why on Earth would a nurse cause more wounds to his body.

(3) Duke Home Health Care RN used miscellaneous tape to join the port-a-cath tubing together. The tape leaked and, therefore, the medicine kept dripping out. Obviously, the pieces did not fit together on their own.

I contacted Duke Home Health and we spent over 2 hours arguing on the telephone about where the tube was leaking! Ridiculous.

I took dad to the Duke infectious disease clinic to have the port access replaced.

(4) Duke Home Health Care did not have the discharge orders. I had to provide them with the hospital discharge paperwork. The nurses had no idea about the need for wound care or the weekly blood draws.

(5) Duke Home Health Care did not provide me with sufficient supplies for wound care.

I have purchased the care items myself. What would have happened if the patient had no family or friends to purchase the wound care items.

I was only subjected to home health care for 2 weeks. The quality of care differed dramatically from nurse to nurse. Initially the nurses for the first 2 visits were absolutely awesome. Then, the nurse assigned to dad's case arrived. Night and day.

I do not have a fair sense of what the deal is with the "home health care system." But, I do know that the system is directly linked to the hospitalist program model.

The hospital resource manager feeds patients (and therefore revenue) to the home care system.

And, since the hospital resource manager feeds patients to home health care that do not fit the legal standard, I am uncomfortable.


Post mortem:

I wish I knew why Duke Home Health Care thought they were at my dad's house. Infusion? Wound care? Remember, they did not have a copy of the discharge instructions and did not know about the weekly lab draw orders.

I cannot help but think that Duke Home Health wanted the home PT because Medicare would pay a large reimbursement for home health care and home PT.

I spoke with another Duke PT who told me that she worked as a Duke home PT for patients that were not really home bound. The patients simply did not have anyone to bring them to outpatient PT. This particular Duke PT said she felt uncomfortable signing paperwork that was dishonest about the patient's need for home PT. But, she wanted the patient to receive PT and so she weighed medical ethics over legality.

I betcha this happens a lot. This is an abuse of the insurance system and just perpetuates higher costs.


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