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Red Tape Delays Nurse Practitioner-Ordered Home Care
Could an outdated Medicare regulation be creating care delays that put patients at risk?
Ron Ordona, DNP, FNP-BC, provides primary and urgent care to older adult patients, most of whom are too sick to leave their homes for routine medical care. Many of Ordona’s patients rely on home care provided by a registered nurse (RN) who can monitor their conditions and perform critical tasks such as dressing wounds or making sure they take their medications. Medicare covers this service, but only if a physician signs off on it.
As a nurse practitioner (NP), Ordona is one of many primary care providers whose patients bear the brunt of this rule that can delay care. A fax requesting certification for home care may sit unseen on the desk of a busy physician alongside dozens of other requests for hours or even days—delaying the start of care while a patient’s condition deteriorates.
Last December, Ordona ordered a hospice evaluation for a patient with dementia who was moving toward the end of life. While the home health agency that would perform the evaluation and dispatch a hospice nurse waited for Ordona’s collaborating physician to sign off on the order, the patient declined to the point where she needed emergency care.
“You can only imagine,” says Ordona, expressing frustration at his patient’s ordeal, “someone with dementia, already feeling confused and combative, and in the ER—she didn’t need that.”
Requiring a physician’s certification can delay communication in the other direction too. If a nurse providing home care identifies an immediate need for Ordona to see a patient, the home health agency will sometimes erroneously contact the signing physician instead. Ordona recalls one incident where this kind of delay resulted in a hospitalization. “By the time I got the call,” Ordona says, “bacteria from a urinary tract infection had spread throughout the body and [the patient] needed treatment with IV antibiotics.”
These kinds of delays do not appear to be isolated. Sue Mullaney, DNP, APRN, GNP-BC, heads up a task force that recently surveyed members of the Gerontological Advanced Practice Nurses Association (GAPNA) about their experiences referring patients for home care. Two-thirds of the 260 respondents who said they order home care reported difficulty getting the initial certifying signature and say their patients are “likely” to experience delays in care as a result.