SKILLED NEED

SKILLED NEED

©2009 Kathy Quan RN BSN ALL RIGHTS RESERVED

Intermittent Skilled Homecare means short term intermittent care. It does NOT mean long term care solutions. 

Skilled need basically means that the patient requires the skill of an RN, or Physical Therapist or Speech Therapist to perform and or instruct in aspects of their care. 

(Note: OT does not yet qualify by itself for the initial skilled need, but can continue once the plan of care is established, and can re-certify.) The nurse or therapist learned these skills in school or in the course of their ongoing professional training. 

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Although the skill such as wound care, diabetic care, IV infusions and line care,  subQ and Im injections,  prescribed exercises, transfer techniques, etc., can be taught to the patient and/or caregiver, they do (at least initially) require the education and skill of a professional nurse or therapist to perform and to teach this skill.   

Then the professional provides the skilled care of supervision and re-assessment to evaluate whether the care is progressing as it should or requires some changes. If changes are needed, the RN or Therapist instructs in the changes needed.

The skilled need then becomes supervising and skilled assessment for accuracy, compliance, necessary updates or changes, side effects, infection, complications, etc. These do not justify long term continued care however. 

The patient/caregiver can be taught what to look for and when to seek medical care and when competent, be discharged back to the community for follow up with the physician.  If complications arise, the patient can be referred again for further home health care. 

Homebound Status Clues to Skilled Need

Usually the homebound status and the skilled need go hand in hand and one supports the other. The reason the patient is homebound often presents complicating issues that establish the skilled need for patient/caregiver education or intervention.

If, for instance, the patient is bedbound, a skilled need for instruction in care of the bedbound patient is established, but this needs further evaluation and qualification as to how long this condition has been present and what complications are present or at risk. Is there a desire to change this status and are measurable gains possible? Or does the skilled need only call for instruction in safe care of the bedbound patient. This could be for a new situation such as a new caregiver, or an initial occurance of the bedbound status to protect the health and safety of the caregiver as well as the patient. Preventing skin breakdown, preventing aspiration, and ensuing optimal health of the patient within the confines of the bed are all skilled needs that can be quickly taught to the lay person. 

PT

For example: a one-time re-instruction session from the PT with the patient and caregiver for the patient who has been bedbound for a long time, but presents with new consequences or challenges. Or if there has been a change in caregiver(s), the need for education in caring for even a long-term bedbound patient is a new skilled need. Careful documentation will demonstrate and justify this need. 

Changes in condition can present an opportunity for the patient to improve, the PT can evaluate for this possibility and establish new measurable goals and a plan of care to attain them. 

If however, nothing is new or changed since the skill was originally taught to the patient and/or caregiver, the skilled need is no longer there. 

On the other hand, if this is a new status or a change in condition such as the development of decubiti, then wound care along with extensive teaching and skilled observation and assessment of all aspects of bedbound complications may be needed.

Digging for the Skilled Need

Even the vaguest patient referral can sometimes be justified as a skilled visit with one follow up visit to reassess, provided the homebound status can be established and well defined and documented. The admitting nurse or therapist may have to become Sherlock Holmes, but with some strong investigative skills, the need can often be established. 

For example, decreased mobility (or what we may also call “the dwindles”) at any age can present complications with elimination patterns, nutrition and hydration status, circulatory complications, skin breakdown and home safety issues. 

Further, what might be the underlying cause for this condition? 

bedbound
  • Are there issues to explore such as poorly managed chronic illnesses such as heart disease, or diabetes? 
  • Is there an isssue with acute or chronic pain control, pulmonary retraining, depression or other mental health issues, etc? 
  • Would the patient benefit from PT, OT, or an MSW? 


Your follow up visit would be to re-assess understanding of your teaching and follow through. Make appropriate referrals and discharge as soon as possible.

Clues From the HomeBound Status

Sometimes the skilled need will clue you into the homebound status. Remember, homebound doesn't need to be a permanent status. Are you there for wound care to an infected post op wound? Although the wound doesn't make them homebound, the underlying cause of the wound can be the homebound factor such as any of the following:

  • Medical restriction to home status post surgery and wound infection
  • Significant weakness due to post op status, must rest after ambulating 20 feet
  • Post op bedrest with BRP only;
  • Activity restrictions post operatively
  • Impaired mobility post operatively with open draining wound
  • On IV antibiotic therapy for open wound infection


If in doubt about the validity of a skilled need discuss the case with your team in case conference and with your nurse manager, team leader, and/or administrator. Brainstorm together.

Refer to the HIM11, the Medicare COPs, and/or to your reimbursement intermediary for advice. 


When the Patient Isn’t Homebound

Certainly, if the homebound status cannot be established, then the patient does NOT meet all of the criteria for homecare and suggestions for appropriate community referrals should be provided. 

Remember, homebound status is not always permanent. When your atient is able to resume activities outside the home, it’s time to discharge. Make sure all of your teaching is wrapped up and discharge planning complete. Notify all disiplines to do so as well. 




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