The Z-Factor

Did you ever play Zelda, The Nintendo game?  When my son and I ‘beat the game’ all those years ago, I was very sad to say goodbye to Zelda.  She felt like a friend and I really enjoyed playing it with my son.

In Zelda, players get ‘lives’.  They are represented as little hearts at the top of the screen.  As time goes by or when you get overpowered by the enemy, your lives dwindle down.  But if you look under rocks or find a fairy, you can get more lives.   Whoever said that video games were not realistic did not know Zelda.

So, are you clear about Zelda, now?  Your lives run down as time goes by and you have to do something or discover something magical to increase your lives – Just like payment in home health.

Before we go forward, let me share with you some typical language found in denial letters.

The SN visit notes consisted of general assessment and discussing the disease process with the caregiver. There were no changes made to the plan of care and the· beneficiary remained within the confines of her illness. There was no documented physician contact throughout the episode. Adequate time had been allowed in previous episodes for teaching on disease processes. Based on these findings, the SN services will remain affirmed as not reasonable and necessary.

And then there is this:

The documentation did not support the likelihood of any changes that would require skilled nursing intervention. The beneficiary appeared to be within the confines of her illness with no changes made to the-plan of care. The skilled nurse provided repetitive teaching on existing diagnoses, medications and diet. Prior episodes had allowed enough time for observation, assessment and education. Therefore, denial of all skilled nursing services is affirmed for medical necessity.

In these denials, which are very typical, Nurse Zelda ran out of lives before the patient ran out of episodes.  In some cases, the patient starts out with such a small amount of lives that this happens before the end of the first 60 days.

So. it’s clear how to get more lives now, right?  In order to get to the end of the game which in this case is the patient meeting reasonable goals, Nurse Zelda must keep looking for the fairies who bring life or the magic potion.  According to these very typical denials, that would include things like:

• MD contact
• Changes to the plan of care
• New Medications
• New diagnoses
• Original teaching

This is a partial list of course, so we can look at each of them individually.  I know you can’t wait to read more.

MD Contact       

This is a big deal.  Nurses have been trained to not bother physicians, especially referral sources with petty concerns.  But, there is a balance between irritating a physician to the point that your competitors gain a new referral source and responsible patient care.  If you have to choose, go for responsible patient care.

To take advantage of this strategy to improve lives, consider writing an order on each and every care plan to address parameters.  For those of you who can enter ‘canned data’ in the computer, write it like so:

Skilled nurse to assess the patient according to flow sheet and notify the physician of the following out of range parameters:

• Systolic blood pressure > 300
• Diastlic blood pressure > 200
•  > 106
• respirations > 70
• Capillary Blood Sugars <30 or >900
• Heart Rate <30 or >900
• INR > 10

Some of my sharper readers might notice that these are not useful parameters.  That’s okay.  When a nurse assesses a patient and determines specific parameters for that patient, they will change.  If, on the other hand, he or she simply leaves the computer normals in the blanks, they will be easy to spot on review.  Zelda carefully considers each parameter before adding it to the care plan and contacts the MD for out of range parameters.  It can be a fax or a voice message.  The MD does not have an obligation to leave a patient in brain surgery because of a mildly elevated blood glucose.

Avoid terms like, ‘MD aware’.  How is the MD aware?  Does he just ‘know things’?  Does he have special psychic powers?  Are MD’s the real life inspiration for Link, the quiet but wise and all knowing elfin friend of Zelda?  Do not every assume that the physician knows anything regarding the care rendered by the agency that is not documented as being communicated to him in the chart.  Because your charts are reviewed in 60 day episodes chunks, make sure that important information is replicated each episode.

Changes to the Plan of Care

I know some of you are shaking your heads at my crazy thinking but there are orders other than medication changes that will be recognized as changes to the plan of care.  Too many times, y’all skip right over opportunities to increase lives when a physician communication does not result in a new or changed med.  Consider the patient who had a high sugar but had not had his insulin yet.  Maybe the best care for that patient would be to arrive early and observe him taking his insulin.  Perhaps the patient wasn’t being quite honest with you.  Maybe he was running low on insulin or just forgot.  Ask for an extra visit or two when you communicate with the physician to determine if there is a pattern or if the missed insulin was an isolated event.  The order for extra visits changes the plan of care even though a change in insulin dosage isn’t warranted.

New or Changed Medications

In order to be strong and brave like Zelda, you must go where some clinicians are afraid to go:  the inside of the medication planner.  Assessing the patient’s medications for absent, new, duplicated or omitted medications is like looking for bodies in a grave yard.  There is always something that has gone awry and that something usually results in a call to the physician for clarification which is a change to the plan of care that results in better care to the patient.  This should be done by nurses on each and every visit.  Add that order to your plan of care. SN to check medications against orders each visit and address any new meds, omitted meds, missing meds, duplicate therapy or other discrepancies.

Therapists are not exempt.  It is well within their scope of practice to ask a patient if they saw the doctor or got any new meds since the last visit.  If so, they should contact the nurse case manager so nursing can follow up.

Not only will you save a life or two along the way which is routine for you but you will also be prepared when Medication errors are added to the list of measures that can increase or decrease payment in 2016.  (You read that right.)

Harvard Health Publications reports on a study where half of all patients experienced a medication error after they went home.  Surprisingly (not), the intervention of a pharmacist did not help to a significant degree.  Of course, the pharmacist contacted the patient after discharge via a telephone call.  We have the secret key to the patient house.  Let’s take advantage of our special weapon and use it to save more lives both figuratively and literally.

New Diagnoses

By ‘new’, think of diagnoses that are not included in the plan of care.  These diagnoses may be related to a recent illness or it could be that something major was omitted from the original plan of care.  If so, teach on it if it will improve the patient’s chance of reaching goals.  Have it added to the care plan as in contact the physician as described above. Do not wait and add it at the recert.  If it’s important enough to address, it is important enough to get an order for when found.

Example fax to Doctor:  A review of the patient’s history revealed that she was told during her last hospitalization she had diabetes but is not taking any medications.  Would you like for us to check sugars and draw a Hemoglobin A1C?

Another gold mine for new lives in the form of unaddressed diagnoses is the med list.  There are drugs that people take recreationally and those that are seldom taken if not needed.  If there are any drugs on the plan of care that you do not know, find out what they are!!!  If they are taking Eliquis, there’s a real chance it is not because it has such a beautiful name.  (It’s an anticoagulant – I had to look it up.)

You are failing yourself if you provide care to a patient taking a medication and you don’t know what it is or why they are taking it.  Sadly, I see this almost daily and I genuinely believe it is documentation as opposed to true oversight but when it comes to payment reviews, it really doesn’t matter what I believe.

Original Teaching

I used to like teaching guides.  There are millions of them by reputable institutions geared for all levels of learning available at no charge on the internet.

When people started cutting and pasting from the teaching guides to their notes, my relationship with teaching guides took a turn for the worse.   Why would anyone teach an 88 year old male patient that he should not become pregnant while taking a certain drug?  Or, maybe the information was carelessly cut and pasted from a teaching guide and nobody really knows what was taught while in the home.

Remember who your patients are.  Assess their ability to comprehend given their age, medications and disease processes.  It took us years to fully understand diabetes.  We cannot rattle off information on rotating insulin sites to a patient who does not take insulin and expect said patient to share our understanding of diabetes.  Take your time with teaching.  This is not a race.  This is a documentation challenge.

Better Care and More Money

It costs money to provide the kind of care that makes nurses and therapists proud.  Don’t leave any on the table.  I know that many of these things are being done.  The nurse whose documentation would make it seem as though she never once looked at a med list can rattle off every med and med change for her patients without thinking much about it.  The patient of the ‘bad’ teacher has spent four consecutive visits learning different aspects of diabetic foot care.  If that nurse teaches all her diabetic patients as thoroughly, it is almost certain he or she will save someone the trauma of having a limb amputated one day.

Don’t think this is all about money although I will be the first to tell you that you deserve to get paid more.  Your agency will never be able to pay you more or hire additional staff if you keep walking past opportunities to add extra lives to your patient.

More importantly, this is about patient care.  Every time you find an opportunity to extend the eligibility of a patient it is because you have identified a threat to the patient and addressed it.  That’s kind of important if you ask me.

Comments and further suggestions for your peers are more than welcome.  Play to win, guys.  Zelda is an important part of my history.  Make it part of yours, too.