SKILLED NEED
©2009 Kathy Quan RN BSN ALL RIGHTS RESERVED
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 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 this skill in school or in the course of their ongoing professional training.
Although the skill such as wound care, IM injections, prescribed exercises, transfer techniques, etc., can be taught to the patient and/or caregiver, they at least initially require the education and skill of a professional nurse or therapist to perform and teach this skill.
The skilled need would then become to supervise and assess 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 be discharged back to the community. If complications arise, the patient can be referred again for further 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 needs qualification as to how long this condition has been present and what complications are present or threaten. This can consist of 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.
If however, nothing is new or changed since the skill was originally taught to the patient and/or caregiver, the skilled need is not there. If on the other hand, this is a new status or a change in condition such as the development of decubiti, extensive teaching and skilled observation and assessment of all aspects of bedbound complications may be needed.
Digging for the Skilled Need
Even vaguest patient referral can sometimes be justified as a skilled visit with one follow up visit to reassess, if 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 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, and home safety issues. Further, what might be the underlying cause for this condition? Are there issues to explore such as 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.
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.
Establishing Homebound Status With the Skilled Need (Sample Case)
Sometimes the skilled need clues you into the homebound status. Remember, it 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:
If in doubt about the validity of a skilled need, discuss the case in conference and with your superiors, refer to the HIM11, the COPS, and/or to your reimbursement source or intermediary for advice.
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