Vol. 17 Issue 26
Home Health Forum
How to Deal With Patient Non-Compliance
Question: I've been working for a Medicare-certified home-health agency for nearly nine months. Lately I have had several patients who are "difficult" to work with and I need your advice. One of my patients is non-compliant with her exercise program, another has a caregiver who does not participate when I ask for help with the patient program, another seems to want the home care services just so that he gets a bath aide visit, and the last one cancels on me at least once a week. Help!
Answer: The issues you face are not unusual to those of us who provide skilled physical therapy services in patient homes. The post-BBA PPS Medicare model provides short-term, in-home services intended to restore lost function or stabilize a frail medical patient condition.
We teach our own staff that the limited duration of the current home care model requires a level of patient participation and motivation to achieve successful patient outcomes.
Your question is really how to illustrate these issues in order to orient patients and their caregivers. The answer is to identify the most effective method to motivate the patient and engage the caregiver in the current home care model. If your efforts to do so are unsuccessful, you are to document your attempts and proceed toward discharge.
Home programs are a mandatory component of the post-BBA Medicare home care model. Patient and caregiver participation and follow-through are necessary steps in timely progress toward the functional or outcome-based goals identified during the formulation of the plan of care. It is the responsibility of the home care clinician (PT, OT, ST or RN) to educate and achieve full compliance on this issue.
Initial patient understanding and/or motivation regarding this topic can vary greatly. The skilled clinician should seek methods designed to help the patient actively engage and perform the home program daily. For example, the expectation for participation and introduction of the program itself must be addressed during the initial visit. During the second visit, the home program should be modified in response to patient performance in the interim.
Compliance almost always results in the ability to progress the program's intensity and scope. Noncompliance is often easily identified and must be addressed immediately.
The patient must be refocused on the mandatory element required by Medicare for continuation of services. It is usually mentioned at this point that continued noncompliance could result in discharge. If poor follow-through persists, a written grid-like table is created on the home program document itself for the patient to demonstrate that he is performing the program (i.e., exercises).
Patients' successful participation with resultant documentation on the grid is utilized to either provide positive reinforcement or highlight their further noncompliance.
It is at this point that discharge is warranted and must include physician notification, Medicare Notice of Provider Non-Coverage, and other agency documentation completed as required. In addition, if you are not the only discipline in the home, you may also not be the only clinician experiencing less than desired patient compliance.
The next situation you describe involves a caregiver who declines to participate with the patient program. Again, initial visit education regarding the short-term nature of the home-care benefit and immediate establishment of the home program serves to engage both the patient and caregiver in your plan and focuses everyone on the functional goals. A polite but consistent insistence on the active participation of caregivers increases the likelihood that they may assist the patient with appropriate follow-through and identify with successful goal achievement.
It is not unusual for clients to expect aide services as part of the home care program. Prior to PPS, certified agencies were able to bill Medicare for aide visits as part of the reimbursement structure.
Today's HHRG-based system identifies payment levels based on functional or medical declines and considers aide services an agency cost. The short-term nature of today's home care leads to the concern that the bath aide provision could foster dependency. An OT referral is made to address deficits or equipment needs that can lead to independent bathing or ADL function. Patient education is important in this area.
Your last patient cancels on you at least once a week. There are many ways to approach this dilemma. Some appropriate questions to examine are 1) Is the patient showing progress? 2) Is the patient independent with the home program? 3) Do you still expect the patient to achieve his goals? and 4) Do the decreased visits compromise rehab potential?
If the answers to questions 1-3 are yes, you may consider obtaining a new physician's order for the decreased frequency (don't forget the HHABN). If the answer to question 4 is yes, you should counsel the client and family regarding importance of the frequency you identified in your plan of care and its relationship to successful goal achievement.
If this does not motivate the patient to allow you to make visits according to your initial order, the physician should be notified; an HHABN and possible discharge should follow.
Difficult or non-compliant patients are certainly not unusual in today's home care world.
It remains, however, the responsibility of the home care therapist to educate and motivate the patient to participate in order to maximize the possibility of functional outcome achievement. Your program, and your patient's success, may depend on it.
Question: If a patient lives alone, but her daughter moves in for four weeks, how should I answer the OASIS question MO340?
Answer: According to the 2005 3M OASIS Integrity Project Updated Report (sponsored by 3M, NAHC and Fazzi Associates, Inc), this question identifies with whom the patient is living at this time, even if on a temporary basis.
Ask if the daughter is staying with the patient 24 hours/day, even if only on a month-long basis. Look for signs within the home of the presence of another person living there. You should mark all that apply and exclude any part-time caregivers.
Teri N. Thompson and Arnie Cisneros are both physical therapists in private practices with more than 30 years of home care experience; providing clinical services, management and consulting expertise. They also lecture for Encompass Consulting and Education, LLC, a rehabilitation consulting and education company. You may contact the authors at firstname.lastname@example.org