F Words
August 26, 2010
Most of you can continue on in your web surfing without stopping at today’s post. It is directed to a very small percentage of you who either have or are considering turning in a visit note without actually making a visit. This seems absurd. I know. Who would do that? What could they be thinking?
I have no earthly idea. I do know this. More than one client over the last year has discovered a staff member submitted paperwork for visits never made. These discoveries are not based on the occasional call from a confused patient. They are well documented and leave me with no doubt that some staff members have submitted fraudulent paperwork to Medicare Certified Home Health agencies. And in more than one instance, harm has come to the patient as a direct result of not being assessed as ordered. And every single time this has occurred, I was astonished. Knowing the clinicians involved, I simply could not believe they would do such a thing.
In some agencies, I suspect the culture of the agency is such that not turning a note, forgetting a recert or creating a LUPA situation results in being terminated. If that is the case, find another agency. There are worse things than being fired.
What could be worse than being fired you ask? Well, for starters, if it ever occurs to you to simply write a note and not make a visit, understand that you are committing Medicare fraud. This is a federal crime. Being convicted of Medicare Fraud has and will continue to ruin many lives. Prison is never fun from what I hear. Even if you are not convicted, the lawyer fees will bankrupt you.
Secondly, I cannot think of a single state’s nurse practice act that doesn’t consider fraudulent documentation to be an offense worthy of licensure revocation. If you think it is difficult working in the field for a living, try working at Taco Bell. (No offense to the crew of my favorite fast food restaurant.) And because missing a visit can potentially harm a patient and is related to professional standards, termination for a cause such as this must be reported to the state board.
I know that many of you are thinking this is a silly post. Everyone knows better than to commit fraud. Yet I am always surprised at the people who are caught. And how many are not caught? How many times do we have a small, nagging doubt about someone that is never proven?
When it occurs to you that it will be easy to just submit a note so you can get paid, avoid being fired, etc. get over it. Get fired. Hand in a missed visit slip. Screw up. Be a human. Ask for help. There are three F words at our office. The obvious one, fraud and forgery. If you succumb to the temptation to indulge in the latter two, you find plenty of occasions to use the obvious one.
DO NOT COMMIT FRAUD!
Clinical Pathways Vs Disease Management
August 23, 2010
I am not a fan of Clinical Pathways. Let’s get that out of the way. The pathways I have seen offer arbitrary steps to achieve a goal that may or may not be appropriate for a patient in an arbitrary sequence that is in no way related to the individual disease process of the patient and do not take into consideration comorbidities of the patient.
But a serious, almost pathological aversion to Clinical Pathways doesn’t mean that we can’t improve upon disease state management.
In traditionally offered, academic exercises, we identified a patient with a specific disease process and followed a recipe for care. Thus clinical pathways were born. Disease Management is a little different. When I mention disease management, I assume that a patient has one or more illnesses that has been studied sufficiently to determine best practices. And those best practices, whether they are written for MD’s or nurses should be a part of our practice.
Diabetics should have a Hemoglobin A1c, feet inspections, dilated eye exams, etc. at determined time points. So, if I ask you to tell me when the last time your diabetic patient had a dilated eye exam, could you tell me? If I read your arthritic patients chart, would I find anything other than pain medicine for pain relief? What about your CHF patient? Are you certain that all of your CHF patients are on an ACE Inhibitor? If the MD did not order PT/INR’s for your Coumadin patient, are you certain they are having lab drawn at the MD’s office?
Yes, these are medical interventions. But coordination of care means coordinating care with other providers. Furthermore, this attention to detail will likely appeal to physicians and other referral sources. If I were referring a diabetic patient to your agency, I would want the one who keeps up with everything whether they did it or simply provided reminders to other health care providers.
In fact, a short fax could be generated to the MD upon admission stating that their patient has been identified as having a high risk of complications related to (name your disease) and you are interested in incorporating certain information in the clinical record. And then ask for it. Date of last eye exam, last A1C, weight range, last lab, etc.
Anything not provided by the physician can be arranged by the agency. And if the physician is not interested in playing along with you, it might just be time to find other referral sources.
So ask yourself if you want to improve care to your patient. An overlooked foot inspection or PT/INR is caught and complications are avoided. That gives me a warm feeling inside. It also protects the MD because they have outcomes that are measured for certain disease processes as well. That gives him or her warm feeling a possibly more cash at the end of the year. It distinguishes you from one of the agencies where nurses go in, grab some vitals and teach the same thing 82 visits in a row notifying the MD only when the patient is really bad.
And you get more business. How’s that?
Fluff and Stuff
August 19, 2010
There are many reasons to write a thorough and complete care plan but thorough and complete doesn’t always equate to long. This is especially true where orders are concerned. There exists an overly cautious attitude among some nurses that drives them to include every possible order and intervention that the patient may ever need in this lifetime or the next. The end result is a six page document with crucial information buried between the ‘fluff and stuff’.
Here are some orders I see that make me wonder how they ever hit the care plan.
- Draw Lab per MD Orders. Why put that in your orders unless you have orders? If you have orders, simply write them. If you do not, then you will when you get the orders. Who else besides the MD would write lab orders?
- Teach Diabetic Care including use of glucometer, diabetic foot care, sick day care, rotation of insulin sites, diabetic diet, importance of Hemoglobin A1C, causes of diabetes, importance of exercise and rest, signs and symptoms of hyper/hypoglycemia to report to MD and SN and to report blood glucose levels greater than 300 or less than 50. That is the abbreviated version. It is my opinion that if we include in orders to teach Diabetes care, a responsible, educated nurse acting according to best practices will include all aspects of diabetic care relevant to the patient during the episode. Notice the reporting parameters are buried at the end of the order, easily missed or difficult to locate. The worst part of this order is that it is a daunting task to perform in a single episode assuming the patient has comorbidities. Our patients are not enrolling in nursing school. It seems to me that the nurse who wrote this order didn’t consider assessment data and limit orders to the patient specific needs.
- Weigh patient weekly. Generally speaking, this is a good order for a CHF or renal patient. It only becomes a problem when the patient isn’t seen but once every other week. A better order is to weigh the patient each visit and to teach the patient to weigh self on days between visits.
- Report weight gain of 3-5 pounds. Which is it? Three pounds? Five? If I were playing semantics, I could argue that the only weight between three and five pounds is four pounds. But, surveyors do not enjoy word games as much as I do. A better order is to report weight gain of greater than X pounds with X being determined by the original weight of the patient, the stage of heart failure and prior history.
- Report weight gain of greater than X pounds. While this is decidedly a better order than one with a range it is still not perfect. Consider my client who called me crying. Like me, she was an old Cardiac Intensive Care nurse. Her patient had strict parameters to call for a weight gain of three or more pounds in one week. Over the course of the episode, the patient put on one or two pounds a week. When the patient was admitted to the hospital, the patient had gained over 15 pounds. By placing the baseline weight on the care plan near the parameters, the nurses have additional information to make decisions. Additionally, a weight chart posted near the patient scale will show trends.
I like clear and concise orders. But truthfully, what I like is really not important. What is important is that our care plans are useful documents for guiding the care of nurses taking care of patients. Even surveyors can’t top that reason for writing clear, concise and individualized care plans.
As always, your comments are welcome below. Any other orders you find useless and can add to my list will help both me and your colleagues.
Making a Statement
August 18, 2010
Often when I am reading clinical records I see nurses offering information to patients in lieu of teaching them. I have read an account of a nurse teaching a patient that side effects of Coumadin could cause intracranial bleeding, stroke and death. She further taught the patient to call the MD should any of these side effects occur. I kid you not.
It is true that in the worst case scenario, Coumadin can cause really, really bad side effects including the Big Three (death, coma, convulsions). Similarly it is true that hypertension occurs more often in African Americans and that smoking can exacerbate COPD. I can only imagine a nurse telling a patient in their 80′s that it isn’t a good time to start smoking because they have COPD.
So, yesterday, I overheard an old colleague, Barbara Price counseling a nurse that while she offered a true and correct statement, no real teaching was performed. Statements are not teaching. Observations are not teaching. For the purpose of home health, let’s assume that teaching is the exchange of information that leads to changes in health related behavior.
Note that I used the word, ‘exchange’. Just like an engine needs fuel to run, our teaching machine (read brain) requires information on what to teach. That information comes from the patient by assessment which, by the way, is not mere interview. I cannot emphasize that enough. Teaching requires assessment of the patient and teaching according to their specific needs.
But it must also change behavior. Teaching a non-smoker to abstain from cigarettes does not meet that criterion. Teaching an African American patient that his race may have contributed to his high blood pressure may be true but is it useful? What’s a patient to do with that information? And emphasizing the Big Three as side effects from Coumadin might just induce non-compliance instead of reduce its risk.
Looking at the three examples used already, useful teaching would involve:
| Assessment | True and Correct Statement | Useful teaching |
| Patient is on Coumadin for atrial fibrillation | Patient has very small chance of serious side effects when medication is taken correctly | Take medication at the same time each day. Teach how diet influences efficacy of Coumadin. Teach bleeding precautions.
Emphasize importance of regular lab if agency is not drawing PT/INRs. |
| Pt has been diagnosed with Bronchitis but does not smoke | Cigarette smoke can worsen bronchitis. | Teach patient to avoid cigarette smoke, including second hand smoke. Assist patient in posting ‘No Smoking’ signs in house to prevent visitors from smoking. |
| Patient is an 85 year old black male with hypertension | Hypertension occurs more frequently in African Americans and the treatment is slightly different. | Teach patient that although his race may have put him at higher risk for hypertension, the only way to treat to the disease regardless of race is to take medications, monitor salt and triglycerides, exercise, lose or maintain weight, etc. and then teach him how to do so! |
As always, I am open to your suggestions on teaching. Please leave your comments below. Any new or creative or tried and true ideas or concepts are more than welcome. After all, if teaching was not a skill, we would likely have no home health industry.
Pain Management
August 9, 2010
I have spent a good deal of time this past weekend managing pain – my own dental pain. It is a full time job. I had to plan my meals to be just the right temperature, take just the right combination of pain meds at exactly the right times, avoid ice cream, sleep when I could, etc. It was an exhausting weekend. But today, my pain will be fixed.
What does this have to do with home health, hospice, etc? I was reminded first hand that there is more to managing pain than just teaching the patient to take their medications as ordered. And that is what I see the majority of the time. A patient complains of pain and a nurse teaches the patient to take meds as ordered.
It takes creativity and insight to manage pain. Patients who are not healthcare professionals need our help to do this. Pain management cannot be accomplished without individualizing care plans for patients.
Taking medications as instructed is always important regardless of the med. But just as we do not expect diabetes to be managed by medications alone, we should not expect pain from arthritis, disc problems, etc. to be managed by medications alone. Terminal patients with retractable pain obviously need large doses of narcotics to cope with pain but a good nurse can balance the side effects of narcotics with the patient and family needs to spend quality time together.
Since beginning this blog post, I have spent some quality time with my dentist. My pain has been drilled away. So many of our patients have pain that is not solved by a 30 minute procedure. If ever we as nurses can be of value to our patients it is in the mitigation and management of pain. I challenge you to be as creative and effective as possible in pain management. It takes time and imagination but it is worth it – especially to our patients.
Some suggestions I have learned from my clients:
- If a patient is afraid to take pain pills because they will be hooked, ask the MD if a non-narcotic may help. If so, refer to the medicines as anti-inflammatory meds instead of pain pills.
- Teach the aide to call the patient before visits and teach the patient to take pain meds before the aide arrives to make bathing, etc. more comfortable.
- Pain meds often contribute to falls in the elderly. Teach the patient to eat, void and be in a position to relax prior to taking narcotic pain meds.
- For pain moderate pain, try NSAIDS during the day and stronger pain meds at night. This allows the patient to get rest and participate in household activities during the day.
- Fear exacerbates pain. Whenever possible, reassure the patient that their pain is not a sign of a worsening or new illness and that it can be treated.
- Physical and occupational therapy can teach the patient how to function safely while minimizing pain.
- Be very careful of pain medications containing Tylenol. Many over the counter pain relievers, allergy meds and prescription pain meds all contain Tylenol. It is easy for an elderly patient to get too much Tylenol when on multiple medications.
- Non pharmaceutical pain relief measure may be beneficial by themselves or in conjunction with pharmaceutical measures. Consider meditation, breathing and relaxation exercises, yoga, music therapy, distraction through books and movies, etc. to assist in pain relief measures.
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Remember that any rating of seven and greater on a 1 – 10 pain scale is considered to be severe pain and should be addressed.
Any additional suggestions that you wish to share with readers would be greatly appreciated. As always, you can email me or leave a post below.
