Physicians see it all the time: High-needs elderly patients who don’t qualify for skilled care, but who have complex conditions that may compromise their health and safety at home. These patients often have one or more caregivers, but their basic medical needs still go unmet. The solution? Management and Evaluation (M&E) services offered under the home health care benefit.
These services are especially beneficial to patients who exhibit the following:
- Non-compliant or confused about medications and treatments
- Frequent unscheduled office visits/office calls
- Unmanaged complaints of pain or exacerbations
- Missed scheduled medical appointments/Labs
How it works
An RN assesses the patient in their home and sets up an appropriate nursing care plan to address the following needs:
- Multiple medical problems
- Safety/potential for injury
- Altered mental status
- Deficits in ADL/support system
- Alteration in skin integrity
- Impaired physical mobility
So what makes the “unskilled” part of the patient’s plan of care so complex that oversight by an RN is necessary?
Multiple physicians may be involved with the Plan of Care, yet no one physician is taking the lead responsibility. Also, there may be many unskilled tasks necessary to ensure good outcomes for the patient, such as GT feeding, frequent turning, titration of medications and skin inspections. Often patients benefit from a skilled professional who can oversee all of the facets of their unskilled care, from arranging for medication refills ahead of time and monitoring diet to making sure patients have transportation to appointments.
Under M&E, skilled professionals coordinate caregivers’ efforts to assure the care plan in place accomplishes the Plan of Care as ordered by the physician, that necessary tasks are accomplished and that services are not being duplicated and thereby wasted. Home health nurses identify individual needs, coordinate available resources and set up a plan that will allow many elderly patients to stay in their homes safer and longer.