A growth, if you will, opportunity for many Assisted Living facilities is caring for a more clinically complex resident or resident group. The clinical complexity is very much tied to additional medical and physical frailty, necessitating access at times to skilled nursing and therapies. Most Assisted Living facilities, especially those not affiliated with a national or regional organization with infrastructure services such as therapies, seek services from Home Health Agencies when required. In this manner, the Assisted Living core staff are for resident ADL needs and care primarily, and the intermittent skilled needs of certain nursing interventions and therapies (OT, PT, etc.) are provided by the Home Health Agency.
What occurs when an Assisted Living and a Home Health Agency work collaboratively to serve certain residents with skilled needs, is a bifurcated relationship where roles and responsibilities for resident care and service can get murky. Briefly, here are the two organizational duties for resident care.
Assisted Living Facility:
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- Room and Board accommodations including (typically) common areas, dining/meals, some level of furnishings, utilities, access/egress, outside areas, etc.
- Staff supervision of residents in general and the facility including maintenance and cleaning of the environment
- Resident assistance or direct provision of ADL cares such as dressing, toileting, bathing, mobility/transferring, eating but not generally, feeding assistance.
- Social activities for residents and certain social services.
- Medication management and administration. Facility may/may not accommodate medication ordering via a pharmacy relationship.
- Other services such as religion/pastoral care, beauty/barber, transportation, dietetics, physician, banking, etc. may/may not be available.
Home Health Agency:
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- Physical, Occupational, and/or Speech Therapy as assessed by need and as ordered by a physician.
- Skilled nursing services if required, as assessed by need and as order by a physician. These services typically include education, various wound treatments, complex catheter care, IV services, ostomy care, pain management, etc.
- Services are provided as needed by the resident.
- The Agency must provide training/education to the Assisted Living Facility staff regarding the skilled services/care it is providing.
- The Agency is responsible for care coordination between the two organizations such that, its orders and services are reflected as required by law, in the resident Service/Care Plan.
- The Home Health Agency is also responsible for billing insurance or Medicare and for keeping its own medical record.
- The Agency is responsible for patient supplies as the same pertain to their provision of skilled services.
- The Agency is responsible for maintaining compliance with Medicare Conditions of Participation and it cannot delegate any related tasks or duties to the Assisted Living unless permitted by regulation. Examples include obtaining orders for care, updating physicians as needed, documenting service provision, reconciliation of medications, etc.
Think of the relationship this way. The Assisted Living serves as the resident/patient’s home. This is no different than if the resident/patient lived in the community, in their own residence. One could easily create the relationship via a mental picture of the Assisted Living staff as familial caregivers.
The Home Health Agency’s relationship is then, no different than if the patient resided in their own home. The Agency must assess, develop a plan of care, coordinate visit schedules, document the care, share info. with the patient and the family (Assisted Living staff), and when appropriate, discharge plan and coordinate care for any additional services.
The compliance and litigation perils occur when the relationships between the two become blurry or, when either entity fails to properly meet its separate obligations. Here are the common risks that I routinely see/encounter.
- The Home Health Agency fails to incorporate the Assisted Living in its plan of care and to educate the Assisted Living of the same, especially if follow-through is required on ADL education or support.
- The Assisted Living fails to update its Service Plan for Home Health services, as required. The biggest error I see here is typically with regard to therapy services and the introduction of any new devices (e.g., walkers, canes, support bars, adaptive equipment).
- The Home Health Agency delegates physician and family contact to the Assisted Living for Home Health related service needs.
- The Assisted Living fails to notify the Home Health agency of changes in resident care, conditions, etc. such as noticing a change in skin condition, a change in a medication order unrelated to the Agency’s skilled services.
- The Home Health Agency fails to coordinate care via discharge planning, even though the resident will remain at the Facility.
- The Home Health Agency does not do med reconciliation on each visit, believing that the Facility should update the Agency with any new medications or order changes.
- The Agency is not responsive on a timely basis to resident condition changes including, hospitalizations. The Agency must be on-call and connected to resident condition changes, documenting and addressed service/care plan updates as required, especially post-hospitalization.
The risks associated with caring for a more complex resident/patient in an Assisted Living environment when Home Health services are initiated are many, as indicated above. I suggest Assisted Living Facilities try to coordinate their Home Health offerings, where possible, with a few or even, one agency. With good collaboration between providers, the risks can be minimized. In any regard, both providers need to understand their roles in resident care and make sure, staff are well-versed in their respective responsibilities. I advocate tools/cheat sheets if you will, especially for AL staff, delineating “who does what” and where, resources can be sourced if need be.