Home Health & Hospice

Seven Steps to Reasonable and Necessary Teaching

Homecare Insider, January 4, 2010

Teaching must be reasonable and necessary to treat the patient’s illness or injury or else the agency faces a denial of payment from Medicare.  These seven steps can help build a case.  
Step 1:  Identify the patient or caregiver’s knowledge or skill deficit and connect it to the patient’s illness.  
To review the principles of reasonable and necessary teaching, click on — (Link to Dec. 21 article after it moves from home page.)
Step 2:  Identify the patient or caregiver’s limitations.  
These limitations define the parameters that affect the teaching and response.  Example:  The patient has a hearing impairment.  
Step 3:  Develop and implement a teaching plan to correct or minimize the knowledge or skill deficit.  
Identify a goal (what the patient will learn), determine a target date, and define interventions to accomplish the goal.  
Step 4:  Use the plan of care to support the teaching plan.  
Summarize planned teaching interventions in Locator 21.  Identify a diagnosis that connects with the patient’s learning need.  Detail medications, procedures, safety measures, other items of care, which will be part of the teaching plan.
Step 5:  Document teaching interventions.
Use action verbs such as “demonstrate,” “teach,” or  “instruct.”  Include enough specifics so it becomes obvious what you taught.  Examples:  “Taught patient about meal exchanges in 1800 calorie ADA.”  “Instructed patient in dressing disposal techniques and handwashing.”
Step 6:  Evaluate and document the patient’s response and progress with regard to the identified knowledge or skill deficits.  
The patient must demonstrate progress if you plan to continue teaching.  Example:  “Observed patient remove and discard soiled dressings using appropriate technique.”
Step #7:  Record any changes in the plan of care or the patient’s condition to support extended teaching or reteaching.  
Examples:  1) “The patient sets up medications correctly but still is unclear as to the side effects and precautions, and how to modify the Coumadin dosage as directed by the physician.”  This documentation supports reteaching of side effects and dosage modification.  2) “Instructed patient in modified wound care procedure—irrigation, application of ointment.”  This comment justifies teaching the patient about the changes in the procedure.  Also know when to draw the line on reteaching.  If it becomes evident that the teaching is not having any lasting effect on the patient's behavior, repeated teaching is not reasonable and necessary.

Skilled Nursing Services:  In Focus, a video program, takes a nurse through the four skilled nursing services.  To discover how this program can strengthen Medicare service delivery, click on — http://www.beaconhealth.org/cgi-bin/ccp51/cp-app.cgi?pg=prod&ref=22-440-00.