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Use of Admission Agreements to Establish Relationships
with Home Care Patients
Elizabeth E. Hogue, Esq.
Office: 877-871-4062
Fax: 877-871-9739
E-mail:
ElizabethHogue@ElizabethHogue.net
Establishment of relationships
between agencies and patients is a prerequisite to liability. Unfortunately,
the home health model of care precludes the use of criteria like the patient's
entry into a health care institution to determine when the provider-patient
relationship is created. Home care providers must, therefore, develop other
mechanisms for controlling both the beginning and end of relationships with
patients. When agencies fail to control the establishment and termination of
the provider-patient relationship, the potential for legal liability is greatly
enhanced.
So providers must ask and answer some
crucial questions, including: When should the provider-patient relationship
begin? Are agencies responsible for patients from the moment they receive
referrals? Is the staff responsible, for example, for patients who are referred
via fax at 4:00 p.m. on Friday afternoon?
Clearly, the most appropriate answer
to these questions is that home care providers should establish relationships
with patients only after they have an opportunity to assess patients'
appropriateness for home care. Otherwise, home health agencies will assume
liability for patients who they have never seen and over whom they have no
control, a very risky proposition.
Of course, many patients' and
referral sources expectations are exactly the opposite. That is, they
anticipate that home care providers have agreed to provide services upon receipt
of referrals and will take care of everything even before staff has a chance to
evaluate patients. These expectations were reinforced by cost-based
reimbursement under the Medicare Program when agencies were rewarded for
admitting as many patients as possible and providing as many visits as possible
to them.
Staff must directly confront these
expectations. Visiting staff should tell patients and their families upon
arrival for the first time at the patients' home that they have not agreed to
provide care for the patient. Rather, staff members are in patients' homes to
assess patients for appropriateness for home health services. If the assessment
reveals that the patient is appropriate for home health care, the patient will
be admitted. But if the evaluation shows that the patient is not appropriate
for home care, the patient will not be admitted and agency staff will not
provide services.
Staff should then assess patients.
Patients should not be asked to sign any documents such as consent to
treatment or acknowledgement of the Patients' Bill of Rights until after the
assessment is complete.
This practice is directly contrary to
the procedures advocated by many surveyors. But surveyors' insistence on a this
particular practice that cannot be supported by Conditions of Participation (COP's)
has the effect of subjecting agencies to increased liability because it forces
agencies to establish the provider-patient relationship before proper assessment
is completed.
The rationale given by many surveyors
for this practice is that consent is required before staff "lays hands on"
patients. Such reasoning is not supported by the law. In fact, the law
regarding consent to treatment clearly indicates that no informed consent is
required for routine types of treatment, including physical assessment. In
addition, consent is implied when staff members are admitted to patients'
residences and patients follow instructions to allow staff members to complete
assessments for possible admission to the agency.
Assessments performed by staff should
be comprehensive and include:
- Patients'
clinical condition
- Patient's
ability to self-care or the availability of a reliable primary caregiver to meet
the needs of patients in between visits by agency staff
- Whether
the patient's home environment will support home care services
If this comprehensive evaluation
indicates that patients are appropriate for home care services, patients should
be asked to sign an Admission Agreement.
"Admission agreement" may be an
ominous term for providers in the sense that they may envision a long, complex
document. On the contrary, Admission Agreements should usually include a
combination of the various forms agencies use upon admission, including the
agreement to pay, consent to treatment, acknowledgement of the Patients' Bill of
Rights, etc. All of these forms should be combined into one document that is
called the Admission Agreement.
Some providers are tempted to call
this Agreement something else. This temptation should be avoided because the
point of the agreement is to serve as evidence that the provider-patient
relationship has been established.
The use of Admission Agreements
should be accompanied by an agency policy and procedure that makes it clear that
only patients who have signed Admission Agreements are the responsibility of
agency staff.
If, however, staff members determine
that patients are not appropriate for home care, then no Admissions Agreement
should be signed. Patients should be told directly that they are not
appropriate for home care and that agency staff will not return to provide
services to patients. Needless to say, the fact that this information was
conveyed to patient must be documented.
Field staff should also:
- Notify
referral sources and attending physicians that patients are not appropriate for
home care services and document that they have done so.
- Call 911
and ask for transport of patients in need of immediate care to the emergency
room. Patients who decline transport are likely to have assumed the risk of any
injury they may suffer.
Historically, agency staff members
have sometimes acted from the point of view that something in the way of health
care services is better than nothing. This tendency must be resisted at all
costs. When home health agencies undertake inappropriate care, the risk of
legal liability increases substantially.
©Copyright, 2009. Elizabeth E.
Hogue, Esq.
All rights reserved. No portion of
this material may be reproduced in any form without the advance written
permission of the author.
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