The Nursing Process and The 485 Plan of Care

Ok, go ahead, make your mewling noises....mewling...what a good word, don't you think? Brings to mind small sniffling, wet sounding sobbing broken with sighs drowned in the sleeve of a lonely...What?

Oh good, you are done then? Right. Let's do this thing then!

Medicare changed the way home health was done in 2000. Medicare gave home health agencies 14 years to accomplish all the required changes and be up and going strong by 2014. I was lucky enough to be under the thumb of an RN who believed that she was MEANT to be a nurse. More than that, however, Alesia Porter could see the future and set her steps and all of us who were with her on the path to that future. Alesia, if you are reading this, I bet you are thinking, "Girl you better NOT put my picture up there!"

HA HA

But all of us who were there in the beginning of the 21 st century are still using and still trying to get others to use the information/education/understanding of the Medicare guidelines in home health. What a surprise for me to flee the part of country I had fled from once before only to have many Ah Ha moments once I got back to "home"

It has not been a pleasant trip. Very Sad as a matter of fact. It would appear that soon there will a BIG pay day for the heat and all I can do is stand at the corner and watch.

Enough of the cryptic talk. How do we change things around here?

That is the worst part of all the last eighteen months isn't it? I am as crippled in our beloved desert as I was back there. No one wants to actually change things forever! Geez Bethard what did you think? That if all home health saw it could be done that they would all want to do it too?

Dude, you are soooooo naive!

 But, just so I will NOT forget I am writing it all down, easy to read and digest, no Eegee's needed.

The Nursing Process.

What is the problem?

Come up with a plan to get rid of the problem.

Implement the plan.

Evaluate the results of the plan.

What is the problem?

I know, really simple right? The part I like is where it all starts to rhyme and I can't help but hear, You remind me of the man, what man? the man with power.What power?

Oh, sorry, got sidetracked. again... So you have the thing all mapped out in your head and your physician approves your plan and your home health patient is smiling cause he/she is a part of that plan and your papers are all tidied and tied with a bow!

Wrong. Nothing is as easy as that!

OKAY/back to the beginning. You think it starts with the referral? If your supervisor says she/he has an admit for you to do is that statement stuck in stone? I hope not, otherwise why do they (the home health agency) need you?

HUH?

Yes, you and you alone are the one that decides, in the first 15-20 minutes of the admit whether that person is or is not an appropriate home health referral. You, the professional, is left to decide if that patient will be admitted or not. I know,man, mind blowing isn't it? So how do you the professional know who is or who is not appropriate and please don't come back with that old chestnut about home-bound status!

Well, there I wasn't saying a thing along those lines....but now that you mention it....OK geez you can't please nobody 'tall these days! Correct, you can not.

So where do you go from here if you can't say, uh, who drives the blue car?

You have to put the question to your patient! That question is: "What do you think home health will do for you?" or "Tell me what you expect from your home health team" or even, "Can you tell me what you think are your hardest medical problems and maybe together we can find a way so you can stay home and well for as long as possible!"

Oh dear, she's done it now and truly, she wants you guys to make the patient responsible for his/her own care and she doesn't mean to make them call the doctor with all their problems! Oh, dude, man, look, Bethard wants us, the professionals, to TEACH the patients their disease process definitions, signs and symptoms to report to their nurse and or physician, ways to manage their disease process and the complications that may result if all of the above is not done! Oh geez Louise, just when I was out there seeing 11-12 patients a day and done by 2:00 PM and ALL THAT LOVELY MONEY!

Here she comes again with that ethical, sane, non stressful, empowerment of the patient and no ADR's for the Home Health Agencies song and dance!

What, does she really believe that if you instruct and help your patients that they will actually LIKE living a well and healthier life? Surely she knows that all the people with chronic disease diagnosis are a  HAPPY bunch! They just look sick, they aren't really sick....

Right.

So, once you, the professional have the patient on your side and you know your med-surg then you are ready to turn in the admit?

I was afraid you were going to say that.

Oh yes, the four things. This is where you can really tie the bow and hand in your paperwork. If you follow the OASIS-C page by page and every time you check assess or instruct, then you turn to the next to the last page and find field 21, write down what you will assess or instruct, then turn the page and find field 22 and, here's where the patient comes in! Find out from your patient what and when they want that goal to be met and write that down!

The four things will be what you as the professional will be teaching to your home health patients; but then you knew that already didn't you? None of you guys out there have written taught on disease process and let it go at that, have you? Because then someone like myself, like your supervisor or GULP like the feds just walking through your door would ask for additional documentation wouldn't they? Someone may actually ask you to prove you know your med-surg and make you tell them, wouldn't they? So go on then and start writing it down, you know you are all great nurses and you don't need to be leaned on this way!

The four things goes like this:

Definition of the disease process

Signs and Symptoms of the disease process the patient needs to know and report to the nurse/physician

Methods or ways to manage the disease process

Complications of the disease process that may occur if any of the above is not followed.

Thats it, really, do that with the top three diagnosis and believe me you will have PLENTY to do for the entire episode because once you use the four things it will remind you of your english class and doing sentence disection; the thing just keeps on going and going!

I know, its a beautiful thing when it comes together ain't it? Brings a little tear to my eye, shore and does to you as well don it?

What? You are tired of the vernacular? Well then take off your hat!

A starbucks to the first one who can tell me where I came up with that old one!

Remember not to clutter you work up with all the old diagnosis, if it is not pertinent to the plan of care, right now today, do not write it down. At the same time please be courageous! If you don't have the nerve to actually pick a severity code get out of the kitchen! And yes, its still the same now as it was a decade ago, if you code it as a severity of 2 you must assess and instruct on it so come on be brave! Make a decision and put a number 3 or 4 on that paper/in that point of care and make sure you write it on your patients 60 day calendar so it will all get taught, repeated or repeat demonstration achieved and plotted in the progress towards goals! Now then, you are walking into the new century now!

I know guys, it is NOT as easy as this but can't you see, if you, just one or two of you, take a step today with just one or a few of your home health patients you will see a change in them and in yourself!

I promise it is not as difficult as all this putting it off and maybe Medicare will change their minds and leave us alone has been! Try it once and I bet, I BET! You will never look back again!