Cherry Picking
December 27, 2011
Every year my mother picks cherries. She doesn’t think twice about climbing on
a ladder and reaching over the fence to the neighbor’s tree and picking all the cherries she can reach. She read somewhere that fruit that fell from a neighbor’s tree into her yard is legally hers. She insists she is merely assisting the cherries to fall gently to the ground on her side of the fence where they were going to fall anyway. Then when she gets enough cherries, she fills two big glass containers and pours vodka over them to make Cherry Bounce. I really don’t have a problem with that because my Mama is over 80 and if the worst thing she ever does is make Cherry Bounce with cherries of questionable origin, I think I can live with that.
Cherry Picking patients is another story all together. I am not a lawyer so I will not speak to the legalities of it, if there are any. I am not an ordained minister (if you don’t count the free certificate I ordered off the web just to see if I could) so I cannot offer you moral advice. I am, however, a long time participant of home health in various capacities at various companies and I assure you that I recognize sleaze when I see it.
We all know the agencies who visit patients right up until their benefits run out. In Louisiana, Medicaid patients are seen by one set of agencies in the first part of the year and another set of agencies in the last part of the year. We know of agencies who refuse expensive wound care patients and low paying Medicaid in other states. Proving it would be difficult but I cannot count the number of times that I have been in a client’s agency and a referral came from a discharge planner or doctor’s office reporting they had tried two or three other agencies before they could find someone to accept the patient.
Nurses, excluding the DON, often don’t have much of a choice over setting policies in an agency but we do have the responsibility to advocate for our patients. We can insist on timely discharges and responsible frequencies so that a patient will get the care that they need.
We can also insist that visits be increased when needed regardless of the cost to the agency. It is never appropriate for a financial person to bully a nurse into writing a care plan that doesn’t meet the needs of the patient. It is also not a financial decision to determine if a patient is ready for discharge or needs to be recertified.
Before I start interagency wars, I have experienced that good agencies often have some conflict between the clinical and financial departments. I see agencies thrive when both sides are firm in their positions and each side knows when to relent or compromise. As a nurse, I think every patient needs daily visits and the most expensive wound care products. As a businesswoman, I realize that nobody gets care if the agency cannot stay afloat. It is only when clinicians and ‘money dudes’ have mutual respect for each other that solutions benefiting both the agency and the patient are regularly discovered.
If you are competing against an agency who never compromises with the clinicians and consistently refuses care to expensive patients or low paying patients because of ‘staffing’ shortages, document each event that comes to your attention. If they occur repeatedly, send the information along to your state survey office. They have every right in the world to determine if the agency had sufficient staff for other referrals that day.
If you receive a referral that has been refused by other agencies for financial reasons, ask for the next referral as well. My friend, Ed Lakin, a Marketing Consultant says that too often we forget to ask for business. The referral source can always say no but at least you have made known that you are open to more referrals. (And I do mean, ‘ask’ and only after you have accepted the patient in order avoid the appearance of an inappropriate arrangement where you are bartering with patients.)
When physicians who are Medical Directors of other agencies only refer money pit patients to you to protect their interests, document your concerns. If it happens repeatedly, diplomatically confront him. Smile sweetly and be courteous while you let him know you believe he is behaving in a manner that is an embarrassment to his profession. Do not use those words.
I like making money. I love business. I work all the time to help my clients increase their margins. There are countless ways that it can be done but none of them involve being sleazy.
Sometimes, doing the right thing costs money. When a patient requires care, it will likely be provided. There is always a nurse who can be talked into seeing a patient with real needs. The question is which provider will lose money on the patient?
Hopefully, the same provider who is able to accept and admit high dollar patients will take a hit now and then. If not, the agency that does admit the patient is without a doubt the better agency. Of course, their outcomes may not reflect it because costly patients often are at higher risk for hospitalizations and since their competition only admits high profit patients, it stands to reason that their patients will have better outcomes.
If you have any solutions to this issue, please share them below or email us. It frustrates me when I see this happen and I get paid regardless. I cannot imagine the frustration agencies experience on a daily basis. All of my solutions usually result in long discussions with lawyers and tailors measuring for prison scrubs. Help your fellow agencies out here and provide some ideas that do not jeopardize licenses, marriages or freedom.
Letter to Santa 2011
December 22, 2011
Dear Santa:
First of all, please let me apologize for the letter I sent to you earlier this month. In retrospect, the two word message I sent was a bit impulsive and it ce
rtainly isn’t fit for publication on a site that doesn’t require readers to verify that they are of legal age in their state. If you recall (and I seriously doubt that you do), ever since the kitten mix up, you have yet to get my wish list straight. I know that you drink a lot and if they could grow tropical plants on the North Pole I might suspect your short term memory loss was partly due to cannabis. This year I am going to clarify my wishes in writing so you will have a reference to keep with you next year. Please contact me directly and immediately should you lose your copy.
If you recall, last year I asked you to provide home care nurses with relief from the stressors of too much paperwork. In all fairness, you did that. I just didn’t expect so many nurses to have no paperwork whatsoever as a result of agencies closing subsequent to ZPIC overpayments. It never pays, Santa, to take me literally. You might have have learned that from the two word message I sent earlier this month.
What I really wanted was iPads or laptops for all field staff complete with voice recognition, mileage tracking, GPS capability and wireless connectability. I want Social Security to have everyone sign blanket consents and privacy notices when they apply for social security. That would definitely cut back on paperwork. Is that too much? I think not.
I also asked for Medicare to kind to the home health industry. I gather you are responsible for the vast improvement in manners in all correspondence from Medicare and their contractors. It is so much more pleasant to read about a multimillion dollar overpayment (AKA death sentence) when the notice is written by a well mannered author.
Here’s a clue, Santa. I do not care if Medicare says ‘please’ and ‘thank you’ in letters and I could give a flying flip about telephone etiquette at AdvanceMed (although I must admit, April is delightful even when she denies my requests).
I know that it is considered vulgar in certain social circles to discuss money but I choose to violate my social contract with fellow southerners and ask outright for cash. That’s right, Santa. I want cold, hard cash with which to afford the resources required to care for patients. I think I speak for all nurses when I say we have no objection to accepting money from strange men and you definitely fit that criteria. If you have some time after the holidays please feel free to call me and we’ll run by the Gap and buy you some more contemporary clothing. That red suit you wear is worse than anything John Travolta wore in the 70’s.
Now, I don’t want to be ugly but has it ever occurred to you that you may need us one day? You certainly don’t act like it. Ever since I have known you, you’ve carried extra weight around your midsection putting you at risk for heart disease, joint pain and a lot of other conditions that respond nicely to narcotic pain relief. We can help you get the medications you need. Judging by your spontaneous outbursts regarding ‘Ho’s’, both you and Mrs. Claus are at risk for conditions for which you may prefer discreet treatment in your own home. Do you have any idea what a dent in your lifestyle uncontrolled diabetes or heart failure will make in your lifestyle? Please click here for more information.
Let me recap with two brief sentences. Read carefully and commit to memory if you can.
1. It never pays to get on the bad side of nurses.
2. If you cannot provide what is on my tiny little list, then please let LSU win the Bowl game and the Saints win the Super Bowl.
Sincerely,
Test Results
December 21, 2011
We keep receiving results from the Medicare 101 quiz. What interests me most isn’t the scores that people in general are receiving. Individual low scores could be the result of any number of things besides knowledge. What I find interesting, and occasionally amusing is the number of questions that a whole lot you answered incorrectly.
Understand that green represents correct answers and pink represents wrong answers. Here is the result for the question that reads:
Teaching and training is a skill only if the subject matter taught would be considered skilled care by a nurse.
And yet, isn’t that what we do every day? We teach and train on medication administration but giving meds is not a skill. We teach a patient how to eat a nutritious diet altered specifically for individual disease processes. The real question to consider is whether or not the teaching is required to improve the patient’s condition.
The problem with teaching is that we never seem know when to stop.
Look at question 34. The question read:
Your patient was admitted 7 weeks ago after being diagnosed with CHF and continues to refuse to adjust his diet resulting in multiple hospitalizations. He is able to verbalize all the components of a sodium restricted diet. As you knock on the door, you see him through the window eating a hotdog and some french fries. What do you do?
Most of you got it correct but a full 30 percent of you were ready to ditch the patient as soon as you could. Could it possibly be that compliance with diets and meds might require more than education? I used to think so but look how my peers answered the next question which read:
Which of the following is a skill?
So let’s get this straight. The patient knows all about a low sodium diet and yet you find him eating my two of my three favorite foods (chocolate is the third). And 43 percent of you said that teaching the patient a low sodium diet would continue to be a skill. He knows the diet. He is not compliant for a reason. The reason for non-compliance is where your skill needs to be directed if possible. It could be that the patient wishes to die and wants to prolong the process because it’s a once in a lifetime event. Or, it could be that he cannot afford the food or is completely dependent on his son who spends most of his father’s money on crack cocaine for food so he is stuck with hotdogs and fries. Social workers come in handy in these situations. Revisit post about teaching versus coaching. Try something new. Teaching has already been tried and it apparently didn’t solve the patient’s problem.
The overall scores for the Medicare 101 quiz was 75 percent. There are a couple of questions that I must have written poorly. 78 percent of you think that verbal orders should be cosigned by the physician prior to billing if at all possible. There’s no ‘if at all possible’ about it. Orders MUST be signed prior to billing. When 78 percent of you think otherwise, I either posted this on the Federal Prison blog or the question is just too confusing. Forgive me. I wasn’t trying to trick you.
We are planning a two day conference which just so happens to coincide with the LSU/Alabama football game on January 8 and 9th. The first day will devoted exclusively to the fundamentals of home health including coverage. If you feel that you or one or more of your nurses should have scored better, consider joining us.
The Ugly Step Sister
December 14, 2011
Mandy Estes, Haydel Consulting Services LLC
Okay, so it probably wasn’t nice of me to put Mandy’s photo near the Ugly Step Sister title. It is a coincidence, I promise. I was going to introduce Mandy to you as I published her first post for our blog but I think she did a pretty good job of that herself. Mandy can be reached via email any time you have a question or comment. I hope you appreciate her unique take on things as much as we do.
For those of you who don’t know me, I am Mandy Estes. I have gotten a chance to meet some of you lovely nurses out there when I visit, and the best part of my job is meeting new people and getting to “visit” as we like to say here in south Louisiana. I have worked in homecare for a while now for a LARGE company and a small company and now I am blessed to be employed at Haydel Consulting. Can I say I love my job? Who wouldn’t love their job, if it sometimes consisted of writing a blog about the results of a Medicare 101 quiz? Regulations and tests make me giddy.
Throughout my home health career I have familiarized myself with state minimum standards, but I had not sat down and actually read the federal guidelines from front to back until recently. If you haven’t either, you should at least get started. Below is a link to them, it contains very valuable information and will only make your agency more successful. So, let’s get back to the subject at hand.
Observation and assessment. I want to call it the ugly step-sister to teaching and training. Overuse of observation and assessment is like sending and engraved invitation to Medicare that reads, “Hey, Medicare send the contractor to look at my charts!”
I don’t think anyone was too sure what to do with question 46, because the guidelines are somewhat vague when it comes to continued observation and assessment after the golden 3 week time frame. I could quote the guidelines verbatim but I don’t want to bore you all so much that you unsubscribe to Julianne’s funny and informative blog on my first attempt.
In a nutshell, the guidelines say this is justified as a skill when there is a risk for complication or exacerbation, but in addition the nurse is evaluating for modifications in the treatment plan. This means they actually want us to do something about the problems we are observing and assessing, not just stand around and write a detailed nurse’s note of our findings. We have all done it; even me.
Make a plan then take action by writing a case conference or calling the doctor’s office. In order to meet criteria, the plan of care must change.
The guidelines specifically address that a longstanding pattern of watching and waiting is not reasonable and necessary.
Let’s all make a pact to read section 40.1 of the federal guidelines focused on skilled services. If you will learn something you didn’t already know and maybe you can share it with the rest of us. Experience tells that if one person missed something, chances are a lot of people did. Education is a powerful tool and in our industry education is a must! Stay tuned, there is more to come.
Happy Thanksgiving!
November 23, 2011
Thank You!
I am so grateful for all the good nurses out there. I know what you do for a living because I’ve done it myself. I know many of you will be seeing patients and taking call over the holidays. You will give up time with your own families to tend to the needs of patients whose own families couldn’t be with them.
When I originally got my license I worked every single holiday for 23 months. It broke my heart to leave my child and my family to go to work. It just didn’t seem fair. I know that patients are sick seven days a week, 52 weeks of the year but every single holiday? You would think that by putting all of your heart and soul into your job you would at least get a little respect but patients do not think of the nurses who be taking care of them on thanksgiving when they eat a steady diet of fast food and the occasional steak for 20 years running.
I was close to just quitting my first nursing job in CICU when I was scheduled to work on Thanksgiving for the third consecutive year. That was 21 years ago. My cousin, Sandra, had been diagnosed with stage IV breast cancer and because my family is half Jewish and half Catholic, Thanksgiving was always our big family gathering. I did not want to miss the last Thanksgiving with Sandra.
Right before I did something stupid while feeling sorry for myself, I had an epiphany. If we wait until thanksgiving to show our gratitude, we will miss too many opportunities to be with our families and to let them know we care.
Research shows that people who express gratitude regularly are happier. I keep Thank You notes on my desk and try to mail at least a couple every week. They are constant reminders to stop and consider what a wonderful life I have.
I am thankful for all of you who stay with my ramblings throughout the year. I appreciate the emails and the comments – even those that do not agree with my position. Y’all make me think and reconsider my opinions on a daily basis. That makes me a better nurse and consultant.
I am thankful for the humor in my job even when the source was not intended to be funny. If you don’t find a referral to a paleontologist documented in a clinical record funny, you probably don’t have a sense of humor.
I am thankful for the Zone Contractors, oddly enough. It is good business and it gives me an opportunity to really be of use to clients who want to do well. They also shut down the agencies who have no desire to do well. That works well for my clients.
My Dad loaned me money eleven years ago to start my company. I appreciate him, too. If you happen to see him, please do not tell him. I haven’t paid him back yet.
Two thanksgivings ago, I did CPR on my son. It was like every code I ever attended had prepared me for that moment.
He got a new dog a few weeks ago. With God as my witness, neither one of knew that American Bull Terrier was the official name of Pit Bulls. I am thankful Priscilla doesn’t know that either. So, if I seem a little chipper sometimes, a little too optimistic, a little too happy, look at the picture above taken in my office a few weeks ago. You will understand why I wake up grateful every morning.
Oh, and I just talked to the fam. Sandra is busy directing all the chaos that we call Thanksgiving. She is good at that. I am good at hiding out in my office while all that commotion takes place.
