Not Much Left to Say
March 18, 2010
So, my cousin, Frank died yesterday. He spent almost a month in ICU with ARDS subsequent to H1N1. It was not a good time for our family and there really isn’t much good to say. But that isn’t to say that there is nothing good to say.
My cousin’s son, FJ who is 25 years old and now the man of the family, called me yesterday when my cousin’s doctors were running out of treatment options. It was a dire situation and he knew it and it all came down to the familiar waiting game. As we waited, FJ told me that the whole experience had given him a lot to think about and that he was thinking about changing his major to nursing.
There are several nurses in our family but FJ has never really seen us at work. Before this week, he never really considered nursing as a career. He honestly doesn’t know the difference between Levophed and sudofed. But somewhere along the way, the ICU nurses at the Baton Rouge General inspired FJ to at least think about growing up to be just like them.
This is easy to imagine when a patient in a dire situation is admitted and through heroics, the nurses save lives and restore a patient to good health. That obviously didn’t happen.
It says so much more that a team of nurses was able to care for a very complicated patient without losing sight of their number one priority of being compassionate to both the patient and the family.
Imagine doing your job so well that even when the outcome is not desired, a family member decides to be just like you.
The medical care my cousin received from numerous doctors was amazing. For this I am eternally grateful. But I am not ‘one of them’. I am a nurse, though and I was damn proud to be ‘one of us’ as the nurses gave my cousin every chance to live while at the same time, letting Frank die with dignity. What an amazing accomplishment. I am so proud.
As all of us go through the motions of our jobs, we should remember that we never know when someone will be looking towards us for inspiration. We need more nurses who go into the field because they are impressed by our ability to care for patients rather than our starting salary. We need nurses who realize that good nursing care is not always heroic and dramatic but is important in ways not seen on TV. We need nurses who remember that patients come with families and we cannot care for a patient without caring for the family.
If I Were a Recovery Audit Contractor
March 4, 2010
If I were a Recovery Audit Contractor, I know pretty much exactly how I would choose my targets for review. After all, we know that that the RACs can use statistical information from electronic sources to select agencies to review. By looking at aberrancies in data, I would choose the following triggers to guide me in my work:
- High case mix weights. This is pretty much a given since agencies with very low case mix weights may be under-billing.
- High therapy utilization. Nothing brings up a case mix weight more than therapy! Prior to 2008, there were many patients who needed 10 or 11 visits to meet the therapy threshold. Now the same patient might be assessed as needing seven or 14 visits! Very few patients receive 12 visits anymore.
- I would look for a lot of technical stuff. If I wanted to prove a diagnosis wasn’t appropriate, I would have a lot of clinical record review to get through. Then, when I adjusted the case mix weight based on diagnosis coding, I might find a couple of hundred dollars. On the other hand, if a physician didn’t date his or her signature, I get back the entire HHRG.
- All things being equal, I would choose agencies with very long lengths of stay. While it is true that a Medicare Beneficiary is entitled to unlimited episodes of home health as long as they have a qualifying need, documentation tends to become stale after a while. Homebound status is a little more difficult to discern by clinical record review but when I am reviewing clinical records, I can’t help but wonder about patients with multiple missed visit reports.
Does this mean that you should avoid patients who need therapy and have a high case mix weight. I do not see that as a valid answer. But when time is limited and you must pick and choose clinical records to review for completeness, these are the types of patients I would choose. I would also keep all these factors in mind at case conference. Front end protection in a RAC situation is most certainly better than trying to address problems after the record has been requested.
If you have comments or questions, please post below or email them. If you have any other ideas of what you would do if you were a RAC auditor, please share!
Nothing Special
March 1, 2010
It has been a long couple of weeks for me! Sometime in the middle of feeling overwhelmed, it occurred to me that I am living the life of many of our patient’s families.
My Aunt fell and broke her hip last week. My uncle, her husband is suffering from some sort of dementia and is unable to care for her. Because they live in a rural area, her surgery took place an hour north of their home and my uncle was unable to stay with her. Fortunately, my cousins drove him back and forth to visit.
Meanwhile, another cousin was admitted to the hospital in Baton Rouge. He is in ICU with a diagnosis of ARDS although no one can figure out the underlying cause. Needless to say, our family is spread thin, we are trying to make decisions and give advice long distance and we all feel inadequate because we are not able to be in two places at once.
What occurred to me over the weekend is how common this experience really is. How many times have you been into a patient’s home and learned of another relative either nearby or away that was also gravely ill. There is nothing special or unique about being pulled in multiple directions when more than one relative is ill.
And we have it made compared to many of our patients. This branch of our family tree includes many nurses and two physicians. All of us have cars and the ability to take time off work without worrying about being able to eat or pay bills at the end of the month. We are so much more fortunate than many of our patients and their families.
I know that I would forgive myself if I forgot to make a trip to the drug store or misunderstood some directions that a home health nurse gave me. I see my cousins who are not in the health care field try to make sense of all the information and how easily they become confused. Nurses and other health care providers spend years learning the vocabulary of our industry. What about the teachers and electricians?
And so when we are dealing with family members who are hopelessly non-compliant, I wonder if we are always fair with them? The fatigue of being vigilant all night long for a patient with a broken hip is exhausting. Waiting rooms are not a place to get rest.
Maybe in those first few visits when a patient returns from the hospital we should focus on teaching ONLY what is necessary and eliminating opportunities for confusion. Maybe we should focus on doing more than teaching. Implementing fall precautions with the permission of family members (lifting throw rugs, providing for adequate lighting, etc.) may be more effective than instructing someone who hasn’t slept well in several weeks. A simple phone call to follow up on medication compliance in those first few days may prevent serious complications due to the forgetfulness of fatigued family members.
It has only been a week since all this happened. I have a great family that’s actually pretty big. All of my family members have stepped up to the plate in this stressful time. And we are tired! My attitude towards seemingly non-compliant family members has changed tremendously. I hope you learn a little from my experience and that you keep it in mind both when taking care of patients and in your personal lives.
If you have any questions or comments, please email them or leave them in the box below.
