As you know, my Mom has had a bone marrow transplant.

Twenty-five days in the hospital with very limited mobility. Bed, recliner, bathroom in her room, and a BOAT LOAD of meds.

They did NOT proactively recommend home health.

I had to ASK for home health, and they required a PT and OT from the acute hospital to do an assessment. PT said yes. OT said she didn’t “need” it. (you read ALL about my mind being blown on the last blog about that – if not, read here)

Now you are caught up.

D/C day!!! WOOO HOOO! I am thrilled! I was disappointed with the “no OT” order, but I knew I could address that with the nurse at SOC.  

I have a preferred provider in OH and PA, and I reached out to them. They are an old client of mine, and I wanted my Mom to go there. I know the VP, and I know the marketers. I wanted my Mom to get good care and help them out with a Medicare patient. 

Unfortunately, like a lot of agencies right now, they didn’t have the staff to admit my Mom. So, I was ready for the patient choice list. I wanted to see it. I was curious how they were going to present it.

And guess what? THEY DIDN’T PRESENT ME WITH PATIENT CHOICE!

OMG, here I am, waiting for the big REVEAL! I was sure it would come on a piece of paper with the hospital-based Home Health at the top of the list! But NO!

No choice!

I ask the nurse who we are having for Home Health. She didn’t know. My Mom was chomping at the bit to get out of the hospital, so she was like, let’s get out of here. You are not tracking down the Case Manager or Nurse Practitioner to find out.

We discharge, and I take Mom to her little Air BnB that we stay in for the next 70 days while she receives follow-up treatment and settles into the house.

The Home Health nurse calls to schedule a start of care. She introduced herself to me and asked me to come the next day for the SOC. I say yes, of course, and anxiously await the nurse so that I can tell her that she needs to tell her Marketer to go to the bone marrow clinic coordinator and tell her how awesome Mom is and to have Home Health as a standing order on all bone marrow transplant (BMT) patients who are discharging. 

(Reminder we are in Cleveland – no family – no friends because she doesn’t live here, and even if we were at “home,” Mom is supposed to isolate anyway due to her immune system and WBC at 1.4, so read this as “NO SUPPORT” beyond me and her – PERFECT Home Health patient).

The next day – The nurse is on time and fantastic! Guess what? 

NOT the hospital-based Home Health!!!!

This was a private home health agency, and I said to her – OMG, I thought you were going to be Cleveland Clinic Home Health (because on the phone, she just said – “Hi, I am Payton, the home health nurse – she didn’t say which home health) She laughed and said, “No I used to work there but not now.”

She did all the right things, completed a medication reconciliation on the 17 meds Mom takes twice a day, and taught Mom how to flush her Hickman and wound care. All great stuff! When I questioned her about the other disciplines, she said you had ordered OT and PT. 

Yeah! Someone along the way added OT! GREAT! We are so excited!

Mom is in a lot of pain; she is weak, HUGE fall risk, her balance is way off, and the pain meds make her cogitatively slow. All the things you would expect on a patient who was in the hospital for 25 days AND had a bone marrow transplant.

I shared with the nurse my experience at the hospital and how they didn’t offer Home Health. 

She reported that it was “crazy” I suggested they let their Marketer know. She said, “OK .”I also shared that we had clinic on Monday and Thursday, so could she please let the other disciplines know that we need visits on Tuesday, Wednesday, or Friday? I watched her type it into the Tiger Text for my Mom.

I also shared that my Mom doesn’t answer her phone and would they text or call me to schedule the appointments. I watched her text that to the group too. She reported her frequency would be once a week because that is when my Mom needed her dressing change and her line work for her caps to be changed. Perfect. 

This is a solid care plan for my Mom.

Here is where it gets a little shaky. No call from the OT or PT. I appreciate this. I have agencies I work with now that PT is out for one week. It’s not what we want for our patients, but it does happen.

The part of a patient’s family is the no-call that doesn’t feel good. Of course, I am an OT. (full disclosure I have not treated a patient in over 20 years, so I am a little rusty) While it didn’t feel great that the PT or OT or anyone from the agency called, I was not in trouble by myself with my Mom. I put “oil” on those old skills and cranked them up!

She needs assistance with all ADLs. I believe all the support and assistance my Mom needed would have been a challenge for anyone who doesn’t have the biomechanical knowledge for transfers, bathing, and compensation techniques while dressing and grooming.

I didn’t call the agency to see what would be the outcome for PT and OT, knowing that I could handle the care.

Monday rolls around, and no one has still called. I texted the nurse she said that she handed Mom’s case off to another nurse and she should be calling me for a schedule, but she would check in with the OT and PT.  

The nurse texts back and says the OT and PT had “tried” calling, but no one answered. So I double-checked my Mom’s phone for missed calls or VM – nothing. 

Since I was texting, I told the SOC nurse to please give the OT and PT my number to schedule. The OT called within 3 hrs to schedule an eval the next day between 3-4. Unfortunately, the PT has not called yet.

Today during the weekly visit, I asked the nurse if they had a marketer because I would like to share our experience of not being offered home health with the Marketer.

I am happy to give the Marketer the nurse coordinator’s name, email, and pager that she can follow up with to report on my Moms progress, educate the BMT coordinator on Home Health, and hopefully set up standing orders for BMT patients.

The nurse who was changing my Moms dressings and caps for her Hickman reported she would. (I will let you know if I ever get a call from the Marketer)

What can we learn from this experience?

1. Patient choice – NOT ALWAYS! So, many CM, D/C planners, etc. SAY the offer patient choice and same might. My experience is they often use this as a “smoke screen” because they are “supposed” to offer patients choice by their policy. But as I just experienced – NOPE. I can only make an educated guess the hospital-based HH was “full,” and they picked the next HH on their favorites list that had availability.
2. Staffing is a PAIN right now! Every agency we work with is struggling with staffing. I don’t know why the OT and PT didn’t call me. I can only make another educated guess that staffing was a problem, and they needed to push the eval a week for the OT, and it will be more than a week for PT by the time they get here.
3. COMMUNICATION is key. While I appreciate staffing is challenging out there. I would have really appreciated a call to say, “Hey, we got you. We are a little bit out – is it ok if we come with therapies next week?”

I am VERY curious if this clinical staff will contact the Marketer to call me. I have told them I am an OT who works in Home Health now on the marketing side of the house.  

This gets me thinking, and now I am asking the question you to ponder.

Would your staff contact you? Would you get the message that a family wanted to GIVE you the contact of a potential referral source? Does every staff member know who you are? What do you do? Even if they are PRN?

Does your agency reach out to patients or their families and say – “Hey, we got you! PT and OT are on their way. They will be there within X.”

…Or just know what you do when you can’t get there within 48 hrs with all disciplines? Who watches to ensure all disciplines are in the case if ordered? What is the process?

This is not to challenge your ops team. This is so that you can use it in the field as a selling tool. For example, you could say we review all cases on Tuesday and Thursday to ensure all disciplines are in and communicate with the family. This would show your referral sources how you care for their patients in these trying times of staffing.

These opportunities are gifts to help us grow and serve more seniors!