A Venue of Hope
By Melissa Jeremiah
Pictured are the psychiatric registered nurses from Hoosier Uplands Home Health Care: Lee Sanders, Michelle Shipman and Debbie Guthrie.
Alzheimer’s, depression and other psychiatric conditions affect persons from every gamut of life. They affect the person with the diagnosis, and all of their loved ones and friends. For the many people like these, home health psychiatric evaluation and training services are often an untapped resource. They are provided by home health psychiatric RNs and can be a venue of hope for both patients and their family members.
Educating patients on how to manage their symptoms allows them to remain in their homes longer instead of in institutions and not be frequent flyers to the ER. The key to success is in the hands of home health. Agencies can provide the needed education via therapy and psychiatric evaluation.
It is difficult to ascertain the exact number of home health agencies that provide these services. However it is an underserved — and needed — area of the field. The Centers for Disease Control and Prevention estimates that “twenty percent of people age fifty-five years or older experience some type of mental health concern.” They can get help from home health nurses with the right background and skills.
According to CMS Publication 100-2, Chapter 7, §18.104.22.168, “Psychiatrically trained nurses are nurses who have special training and/or experience beyond the standard curriculum required for a registered nurse.”
In order for your nurses to participate in the Medicare psychiatric care program you must send a letter to your intermediary requesting approval for your agency to perform, psychiatric evaluation and therapy in the home. For Palmetto GBA you must also include the name of the RN who you wish to perform this service, along with a resume highlighting their experience as a psychiatric registered nurse. In addition, find out the requirements your intermediary may have. Put their letter of approval, along with all the other relevant data in your nurse’s personnel file. Also be aware of an added proviso when you send your nurse out.
CMS Publication 100-2, Chapter 7, §22.214.171.124, states, “The law precludes agencies that primarily provide care and treatment of mental diseases from participating as home health agencies; psychiatric nursing must be furnished by an agency that does not primarily provide care and treatment of mental illness.”
This means that your home health agency is the perfect partner for other mental health agencies in your area. You can be the eyes and ears in the homes of patients who are at high risk of returning to an emergency room or in-patient unit.
Palmetto GBA has a local coverage determination for home health –psychiatric care (L31531), which is very helpful when you are setting up your home health agency’s policies and procedures. You should also refer to your intermediary for their specific coverage criteria.
As per CMS Publication 100-2, Chapter 7, §126.96.36.199 the following is an example of when home health psychiatric services are not appropriate:
A patient is homebound after discharge following hip replacement surgery and is receiving skilled therapy services for range-of-motion exercise and gait training. In the past, the patient had been diagnosed with clinical depression and was successfully stabilized on medication. There has been no change in her symptoms. The fact that the patient is taking an antidepressant does not indicate a need for psychiatric RN services.
On the other hand, CMS Publication 100-2, Chapter 7, §188.8.131.52 gives the following examples of when home health psychiatric services are appropriate:
A patient is homebound for medical conditions, but has a psychiatric condition for which he has been receiving medications. The patient’s psychiatric condition has not required a medication change or hospitalization in over two years. During a visit by the nurse, the patient’s spouse indicates the patient was awake and pacing most of the night and has begun ruminating about perceived failures in life. The nurse observes that the patient does not exhibit an appropriate level of hygiene and is dressed inappropriately for the season. The nurse comments to the patient about her observations and tries to solicit information about the patient’s general medical condition and mental status. The nurse advises the physician about the patient’s general medical condition, new symptoms, and behavioral changes. The physician orders the nurse to check the patient’s blood levels and the meds used to treat their mental conditions. Then the physician orders the psychiatric RN service to evaluate the patient’s mental health and communicate about the need for additional intervention to deal with the patient’s symptoms and conditions.
A patient was discharged after 14 days in a psychiatric hospital with a new diagnosis of major depression. The patient remains withdrawn: in bed most of the day, and refusing to leave home. The patient has a depressed affect and continues to have thoughts of suicide, but is not considered to be suicidal. A psychiatric RN is necessary for supportive interventions until antidepressant blood levels are reached and the suicidal thoughts are diminished further. The nurse also has the responsibility to monitor suicide ideation, ensure medication compliance and patient safety, perform suicidal assessment and teach crisis management and symptom management to family members.
In addition, psychiatric RNs can assist patients with areas such as: observation/assessment, teaching/training activities, medication management, lab draws, behavioral/cognitive interventions, and improving function. While the RN performs these functions, a home health aide may be required to perform personal care and occupational therapy visits may be indicated to help patients regain the ability to perform activities of daily living.
Psychiatric RNs will need to use tools that physicians are familiar with, so they are all speaking the same language. These tools will also help the RNs to show whether progress is being made or not. These tools include: PHQ – 9 for measuring depression, GAD – 7 for measuring anxiety, and the Patient Health Questionnaire/PHQ. You can obtain these screening tools free of charge from Pfizer at phqscreeners.com.
MDWise Hoosier Alliance has a Behavioral Health Toolkit for Primary Care Physicians that has lots of useful information. This can be found at www.mdwise.org.
Psychiatric evaluation and therapy can be provided under Medicare — and Medicaid, if it involves a hands-on skill — and many commercial insurance contracts.
Under Medicare, psychiatric RN care is not separately billable from non-psychiatric nursing care. Therefore, if a patient is being seen for a fractured hip and for severe depression, the payment rate is the same, as dictated by your OASIS.
Keep in mind that under Medicare patients must be confined to the home. And this is not an issue if patients have major depression.
CMS Publication 100-2, Chapter 7, §30.1.1 provides further clarification when it notes that a patient is considered homebound under the following circumstances: “a patient who is … senile and requires the assistance of another person in leaving their place or residence” or “a patient with a psychiatric illness that is manifested in part by a refusal to leave the home, or is of such a nature that it would not be considered safe for him/her to leave home unattended even if they have no physical limitations.”
Services must be reasonable and necessary for treating the patient’s psychiatric diagnosis and/or symptoms. The patient must have an Axis I Diagnosis as defined in the DSM-IV-TR. This diagnosis must match the diagnosis the attending physician is treating and/or for which the patient was hospitalized.
As you can see home health care agencies can provide a great deal of hope for those suffering from psychiatric illnesses, and their families. Home health agencies need to step up and begin providing this needed service for patients and their families who are so in need of someone to show them there is help available.
Melissa Jeremiah, RN, CHCE is the Director of Operations at Hoosier Uplands Home Health Care and Hospice in Mitchell, Indiana. Melissa serves on the Indiana Association for Home & Hospice Care Board of Directors, and is currently the Co-Chair of the Home Care Committee. Melissa has also served on the NAHC VHCAA Advisory Board since 2008.