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Veteran’s Day


When I looked up Veteran’s Day on the internet earlier in the week, the first links that appeared were related to office closures such as banks and public offices.  There was nothing about actual men and women who served in the Military.  But, there is a lot going on with the Veteran’s Health Administration and I learned some shocking facts about Veterans when researching this post.  First, approximately 8 percent of our prisoners are veterans.  The good news is that the number is falling and while there are probably a few veterans who simply committed crimes unrelated to their service to our country, many of them have PTSD.

Prison is the extreme but there are many more veterans who are suffering from PTSD.  I never thought of it as a condition that affected the elderly but Dementia and PTSD have a relationship.  Additionally, the traditional treatment of long term use of benzodiazepines to manage anxiety with PTSD is now suspected of contributing to Alzheimer’s Disease and other Dementias.  Medication recommendations have changed and are successful, but Dementia and PTSD are still closely correlated.  These are our patients – Medicare beneficiaries who fought in wars that ended long ago continuing to suffer from PTSD and losing the cognitive ability to cope.

Although younger men and women in the military are taught how to recognize PTSD and get help when needed, the older generation lived in an age when they were supposed to ‘suck it up’.  They viewed mental illness as weakness.  They had a preconceived notion that men were supposed to be ‘strong’ and boys didn’t cry.  Some of them have lived miserable lives.  But as they are approaching the end of their lives, you can help them by learning to assess for PTSD and assist your patient in getting the help they need.

The Veterans Health Administration has a seemingly unlimited amount of information available for Veterans and Healthcare Providers.  There are continuing education courses online at no cost for nurses that grant credit.  There are teaching guides that can be downloaded that will help you teach your patients about PTSD. They are yours by clicking the blue box.National Center for PTSD homepage

When I worked in critical I took care of a patient shot six times by her retired husband.   According to her family, they were the perfect couple but a flashback to a combat zone ultimately caused the death of my patient.  A few years later, in the cath lab, a patient with Alzheimer’s Dementia became very angry when a physician of Asian decent walked into his room prompting the patient to scream something about killing those Japs.  The physician was a kind man and didn’t take offense but imagine how very frightened my patient was thinking that the ‘enemy’ had found him.

Jails are now designating areas for Veterans.  The Hospice Benefit has a program to recognize veterans.  Home Health nurses won’t wait for a program to formally assist Veterans. Let’s get started by learning about PTSD and getting our Veterans Treatment.

They were willing to die for us.  We can lighten the pain of their ongoing suffering.

Schooling Me


Last week, I wrote about a study that revealed an astonishing fact:  Poor, Black people have worse home health outcomes.   I surmised that we really didn’t have time to do a full literacy assessment; nor did we have the skills to do so.  Oops.  A reader, Kyandra commented that there is a Single Question Literacy assessment and that prompted a day long journey into Health Literacy on the internet.  Some of the information I found truly was surprising – and frankly, embarrassing to us as a nation.

The statistics are wide and varied.  One study estimates that one in three adults does not have the literacy skills to understand written health materials. Most health materials are written at an 8th grade level but the average reading level of adults is closer to the 5th grade level.  Older Americans (i.e. Medicare Beneficiaries) are more likely to be unable to read or comprehend written materials.  Accidents happen, hospitalizations increase and preventative care decreases with an increase in health literacy skills that are basic or less than basic.

Should health literacy statistics bore you, know that effective January 1, you are mandated to have a working knowledge and use it.

From the new Conditions of Participation:

The agency must provide information about rights and responsibilities verbally and in writing in a manner the patient can understand. There must be documentation that the agency has complied in the chart.

This is not new.  It has always been a part of the Civil Rights Act section 504 which applies to all government contractors (yes, you are a government contractor ever since your agency entered into a provider agreement with CMS).  Now it is part of the CoPs.

Finally, patients and/or their families have sued successfully when they were unable to understand consents or other forms given to them.  Judges think that a patient who cannot understand the information cannot give informed consent.  I agree.

During my rambling search, I found one video by the AMA that explains the problem much better than I do and also offers solutions.  If I ran an agency, I would play this video at a mandatory inservice for all employees.

After watching the video, consider using a single question literacy screen that has been proven to be fairly accurate in determining health literacy in adults as suggested by Kyandra.

 “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?”

  1. never
  2. Rarely
  3. Sometimes
  4. Often
  5. Always

Although the assessment is determined to be only moderately effective in research, there’s a good chance that a patient admitting to having difficulty reading medical instructions needs more than a standard teaching guide and I’m pretty sure that creative nurses will be able to accommodate those needs.

Nicole White from Chicago commented that she used a sheet of paper handed to her patients.  It had several goals written in a font similar to that found on medication bottles.  She asked them to choose a couple of goals they would like to achieve.  If they couldn’t read the sheet, she asked if she could fetch their reading glasses from another room.  She assessed patient specific goals, vision and literacy without adding time to her assessment.

Nobody is in a better position to dance around problems with literacy than home health employees.  We are in the homes where patients are typically more comfortable.  We get to the know the patients (which may suggest the need for a second screening after a few visits).  We may have more than one person to teach and we can truly give the patient our full attention watching for indications that they are not understanding.  And we can solicit questions.

Agencies can lower hospitalizations, prevent medication and other errors, save a life or two, comply with the new CoP’s, reduce risk and save Medicare millions of dollars when they take health literacy seriously.  And it only costs the time it takes to play a YouTube video and let your nurses and therapists loose to find creative, patient specific solutions.  If nurses can devise a plan to use pool noodles in their care, I’m pretty sure they can use those same skills to meet the needs of their patients.

Please share how you work with patients with limited English proficiency or literacy skills by commenting below or emailing me.

Poor, Black People Have Worse Home Health Care Outcomes


An article came across my desk last week suggesting that Poor and Racial Minorities have Worse Home Health Care Outcomes.  If this surprises you, please stop reading and surrender your nursing license now.

If you read further, the article clarifies the Racial Minorities as Black even though the OASIS data set collects information on American Indians, Alaska Natives, Asians, Hispanic and Latinos, Native Hawaiian or Pacific Islanders as well as white patients.  So essentially, what the article is stating that if you are Black or poor, your health outcomes are worse.

Nurses know that African Americans are predisposed to certain diseases and conditions.  Hypertension and diabetes come to mind immediately. Nearly 42% of Black men and more than 45% of Black women aged 20 and older have high blood pressure.

It is the sequelae of those illnesses that disproportionately affect the black community.  This is where economics comes in and skews the healthcare received by Black people to an unacceptable degree.  Specifically, consider the following statistics:

  • Blacks are up to 2.5 times more likely to suffer a limb amputation and up to 5.6 times more likely to suffer kidney disease than other people with diabetes.
  • Strokes kill 4 times more 35 to 54-year-old black Americans than white Americans. Blacks have nearly twice the first-time stroke risk of whites
  • Cancer treatment is equally successful for all races. Yet Black men have a 40% higher cancer death rate than white men. Black women have a 20% higher cancer death rate than white women.

Additionally,

  • Black Americans are half as likely to get flu and pneumonia vaccinations as white Americans.  See last week’s blog post.

This information is obtained from an article on WebMD

There are so many reasons for these disparities that the study is almost useless to the home health industry.   So maybe the answer is to do what we always done – assess the individual needs of our patients and plan care accordingly.  But sometimes in our effort to be ‘color blind’ factors are overlooked that are closely correlated with being Black and poor in the USA.

About 24 percent of Black people cannot read past a basic level compared to 14 percent White people.  This information is not part of the OASIS dataset and probably shouldn’t be because the time and skills to assess reading ability are not available to us.  There are ways around illiteracy as most nurses know but they take time.  Take your time and be creative.  Send us an account of how your teach patients who cannot read.

Patients younger than 62 who are referred to you may have Medicaid as a primary payor.  In some states, Medicaid provides second rate health care encouraging the use of Emergency Room services when the patient is unable to wait for an appointment set in the distant future.  Medicaid approvals for some medications take time.  We can’t do anything about how the Medicaid system works but we can help the patients navigate the maze.  The truth is that we should be able to treat patients the same regardless of payor source but that ship sailed a long time ago.  If you want to be effective, you must know how the Medicaid system in your state functions.

Poverty and crime have an enduring relationship that isn’t likely to end soon.  Even though you are Wonderwomen and Supermen, you are not able to flash your badge and arrest the bad guys.  Consider the constant stress of living in a home where violent crime is common and how that might affect a patient.  When family members are addicts, patient medications may be diverted leaving a patient in pain unless they want to report a loved one to the police.  I have seen doors with multiple locks leaving me to wonder if there is an escape route in the event of a fire.

In rural areas, crime may not be a problem but the expense of getting to a physician’s office may be out of reach.   Family members may be willing to drive the patient but if they work, they might lose an entire day’s wages.  In these cases, it is possible that truly diligent assessments along with detailed reports to the physician may occasionally eliminate the need for an office visit.

Cheap food is frequently not on cardiac or diabetic diets.  Plus it adds body weight complicating pretty much every disease or condition.  The fact is that poor people eat cheap food and patients who cannot read are unable to follow that food list you gave them, anyway.

As much as we would like to, we cannot teach the world to read, fix Medicaid or reduce crime.  Driving patients to the physician’s office is impractical and basically a bad idea for reasons that would fill another blog post.  You can’t even plant a garden in their backyard to provide vegetables.

We have to look for allies.  Every agency should have a list of community services that can assist us in improving our patient’s’ chances of becoming a little more independent.   It should be reviewed regularly and distributed to all nurses.  Meals on Wheels isn’t the only service available.

We also need to realize that while outcomes are important, there are some things we cannot control.  When someone has untreated hypertension resulting in a stroke prior to admission, it is unreasonable to expect the same good outcomes that result when a patient is referred after being diagnosed with hypertension before a stroke occurs.   That doesn’t mean that we shouldn’t try our best.

The bitter pill to swallow is that our best may not be good enough.  But, it could be better.   Your personal best may be to spend an extra ten minutes with a patient so your functionally illiterate patient can understand the education you provided.  An agency may adopt a policy where breaking even financially on poor and Black patients is acceptable and schedule a few more visits.  Case managers could supplement visits with regular phone calls.  Safety for nurses and patients may be enhanced by an inservice from local law enforcement.

The value of a life is constant throughout races and economic status.  As Malcomb Forbes once said, “You can easily judge the character of a man by how he treats those who can do nothing for him.”  But you may be surprised.  The people who appear to be able to do nothing for you often do the most.

NOTE:  This is an article about African Americans.  I have used the term ‘Black’ because that is what was found in the literature and it is easier to type.  No disrespect is intended.

Guess What Happened!


3D_Influenza_blue_no_key_full_med

Image of the Flu virus courtesy of the CDC.

Guess what happened this past weekend?  The flu season officially started.  Although most people don’t like the flu season, the advent of flu season is better news than the LSU homecoming game score.  Someone should invent a vaccine for the malaise that oozes out of Tiger Stadium and infects the entire state of Louisiana when LSU loses a game deliberately stacked in their favor.  Where is Les Miles when you need him?  I’m not even sure where Troy is.

Back to the flu.  Last year’s flu season certainly wasn’t the worst we’ve seen but an estimated 71,000 flu related hospitalizations were prevented because people received the flu shot.  Is your hospitalization rate high?  Lower it with the flu vaccine.  A full 2.5 Million MD visits were prevented because people received the flu shot.  That’s about equal to the population of the state of Oregon.

We know that Medicare doesn’t give away stuff for free so have you asked why there is no charge for the vaccine?  The total number of hospitalizations for the flu each year runs about 200,000.

And yet, in home health and hospice, our hands may be tied depending state specific pharmacy laws.  In Louisiana, you have to figure that if LSU can’t beat Troy at our homecoming game, we are likely worthless against a deadly virus that kills between 3,000 and 50,000 people each year depending on the severity of the flu season.   Because most states do not allow nurses to carry medications that are not labeled for individual patients, multi-use vials are not allowed to be carried by nurses just in case a patient is in the mood for a flu shot.  While getting an order is not difficult, many nurses are not comfortable with injecting someone with the vaccine without having an emergency kit available for a possible reaction and it is impractical and wasteful to carry around a patient specific emergency kit for every flu vaccination given since it won’t be used.

According to the World Health Organization, for every 500,000 vaccinations given, someone will go into anaphylaxis (a condition causing the inability to breathe kind of like the way Louisiana residents gasped for air after Troy beat LSU on Saturday Night).

There is also a small but significant risk of coming down with Guillain-Barre’ after the flu vaccine.  Although this is one of the more undesirable effects of the vaccine, many people don’t realize that the flu causes more cases of Guillain-Barre’ than the vaccine.  So, roll the dice.  Get no vaccine and hope you don’t get the flu or get the vaccine and have a tiny chance of contracting Guillain-Barre’.  Of course, if you or your patients opt to forego the flu vaccine from your fall schedule this year and wind up sick with the flu, your chances of coming down with a pesky paralytic illness will be greater than those who didn’t get a flu shot and those that did get a flu shot combined.

So, here’s what you do.

  1. First go to the CDC Flu page.  There you will find all kinds of teaching materials for both patients and staff in multiple languages designed for various education levels.
  2. Check on your state’s regulations about the flu vaccine.  If permitted to do so, get said permission in writing.
  3. If you can’t carry flu unlabeled flu vaccine (much like LSU can’t carry a football), use this nifty widget to find out where your patients can receive a vaccine. You can even put it on your website if you want.
  4. Coordinate with your patients and physicians to get orders for patients who are truly bedbound or live in rural areas so distant that a simple trip to the drug store is out of the question.
  5. Encourage everyone in the household to get vaccinated. Leave one of those cute flyers from the CDC website taped to the refrigerator along with the list of nearby flu shot providers to reach the maximum number of family members.
  6. You can also vaccinate other Medicare beneficiaries in the household if you get orders from their physicians. (Technically, Medicare doesn’t require an order but I highly recommend that you give nobody any medication without one; especially someone you haven’t fully assessed and are unaware of their history and physical).
  7. If your agency is going to vaccinate a lot of people, consider billing for the flu shot. I have no earthly idea of how this is done but Medicare has graciously published a little info sheet for people who know what they are doing.  Note that you can only bill for patients with Part B.

The truth is that no matter what you do, the fact that Troy beat LSU cannot be changed.  But imagine if you or your patients get the flu and are too sick to do anything that takes your mind off the greatest LSU humiliation in recent history.  A situation like that could be the end zone for countless Louisiana residents.

And if you see Les Miles, tell him to come back.

Turning Point


My understanding of the events that shook my world last night is that they began before Hurricanes Katrina and Rita.   Although I am not certain of this, it seems that an investigation into Abide Home Health began prior to the storms but the evidence was washed out to sea.   I can’t say if that’s true or not but it adds a level of interest to the story knowing that the agency had a new chance to do things right and chose not to do so.

The case involved over 20 defendants, illicit sex, a dash of racism, the mother of a prominent football player (The Honey Badger), a large oil company and two Zulu Queens.  For those of you not from the South, Zulu is a Mardi Gras parade and they were Carnival Royalty. This is a big deal in New Orleans social circles.

To be sure, this case was juicy.

Imagine for a minute that you are one Lisa Crinel involved in a romantic relationship with your lawyer when a search warrant is executed relating to a fraud investigation involving your business.  Imagine if it was signed by a federal judge who was married to your lawyer.  Now imagine that you are the lawyer when Lisa Crinel files a lawsuit alleging that the lawyer ‘“never informed Ms. Crinel that it was a conflict of interest for him to represent her and her company while carrying on an extramarital affair with her….”   Yes, indeed.  How else could she have known?  I’m betting the judge was unaware of the affair when she signed the search warrant because it didn’t include a cavity search.

For some people, Medicare fraud isn’t enough.  The original press release from the US attorney’s office in Eastern Louisiana alleges that Lisa Crinel created false documentation to support claims for two employees and her daughter so that they could collect money from the funds provided by BP to compensate real victims of the Deepwater Horizon oil spill.  Classy.

Moving right along, Ms. Crinel had already lost 1M to the feds who seized her property even before she was indicted.  This was interpreted by Lisa Crinel as being racially motivated because they did not seize the property of another Medicare defendant accused of the same crime.    I believe there is a possibility that something, other than race motivated that decision.  Could there have been a previous overpayment?  How strong were her ties to the community?  I have to admit, a beach in a country without extradition might have appealed to me if I were in that position.   I sincerely hope that federal investigators did not simply seize her property and bank accounts with no good reason prior to the indictment because in spite of mountains of evidence, Ms. Crinel was innocent until proven guilty.

The Turning Point

In October of 2015, Lisa Crinel woke up with a newly calibrated moral compass.  In exchange for a lighter sentence of no more than 8 years and an agreement from the Assistant US Attorney that all felony charges be dropped against her daughter who served as CEO, she pleaded guilty.  She explained her decision, ‘because I am in fact guilty, and because I did not want to put the government through the unnecessary expense and trouble of proving this in court. I also pled guilty because I understand that accepting responsibility for the wrongs that I have done is the first step toward correcting them.”

Of course, she also agreed to provide the prosecutors with any truthful cooperation in any way she could.  According to Ms. Crinel, this was a genuine personal turning point for her, not just a legal one.  Yes.  That’s what she said.

The Sad Part

Last night, four doctors were convicted of multiple counts of Medicare fraud.  The longest possible sentence I saw was 170 years although the sentencing date has not been set. yet.  Are they guilty?  I think they are.  I still don’t know all of the details but the Feds don’t lose.   They knew this case was their’s for the winning when they took it on.  They turn away far more cases than they accept and the do not indict until they are certain they have a case.

Of the four, I know one mainly through his office staff.  I know that he was with his grandson who was receiving chemo when his office was raided.  I do not believe this was an accident because I’ve heard too many other stories about the feds arriving when the targets of their investigation were least available.  I have followed behind this doctor and another and read their clinic and hospital documentation for years.  The truth is that they are razor sharp physicians who are responsive to their patients and the nurses who call them for orders.

They are basically good men.

So, what happened? One doc received $3,500.00 a month from the agency – $1,000.00 more than would be allowed by law assuming he worked for the paycheck.  None of the doctors were poor and they all made more money than most people reading this blog.

My anger towards the owner of the agency is what I hang on to while these questions still linger.  Lisa Crinel owned Abide Home Health.  Her daughter was the CEO.  They wrote and signed checks that went to physicians.  They paid a physician’s wife an inflated salary so that her husband would refer patients.

Did the docs approach her asking for a Medical Director position?  I bet they were approached by Lisa Crinel.  And what they saw was a successful business woman in New Orleans – an economic nightmare since the storms in 2006.  They saw someone who had overcome the odds and lived well.  They signed orders because she or her agents asked.  Did they trust that the orders were legitimate?

Did they get a little greedy rationalizing that the dollar amount of money may be technically fraud but they deserved it?

These physicians could not have realized they were risking what may amount to life sentences for the relatively small amount of money they received.  But that doesn’t matter.  The standard isn’t what you know but rather what a reasonable person in the same position has the responsibility to know.

Lisa Crinel had the jewels and cash paid for by the proceeds of the fraud.  She was a New Orleans socialite; queen of Zulu.  She was a leader of the community and she lead dozens of her followers to the jailhouse.  While the physicians earned most of their money providing care to patients, she stole all her money by committing fraud.  And when she ran out of lawyers available for affairs and the BP scheme fell flat and nobody would believe that her African American heritage was the reason the feds were picking on her, she turned on the very people she recruited to participate in her fraud scheme.  I’m not sure I have any respect for her.

And New Orleans has lost two great physicians and two more that may or may not be great.  I’m not disagreeing with the verdict but I still find it sad.   The jury found them guilty and I trust the jury.  But they are guilty of fraud; not of being scumbags who systematically scheme to steal as much as they can from the government.   Sometimes good people break the law.

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