Skip to content

Posts from the ‘coordination of care’ Category

Drugs and Theft


I received an email  fromMedscape about continuing education on Opiates today.   I figured it would be an easy way for me to add to my licensing requirements because I happen to love opiates.  Morphine is my favorite.  Understand that I have only had it once after surgery but as a nurse, I can’t say enough good things about Morphine and it’s friends.

Did I mention that my clinical experience is mostly in the CCU and that I have a lot of hospice clients?

That last piece of information is very important.  Morphine is a great drug for relieving pain and in the CCU, it has the added benefit of dilating constricted arteries which may be causing the pain thereby eliminating the source of pain.

In the home setting, opiates are a different story.  Every day I read clinical documentation and I see where nurses teach patients how to take pain medications appropriately and how to manage side effects.  I read nurses teaching alternative pain relief measures.  Every once in a while I see a chart where I am suspicious of the amount of meds prescribed to a patient .  But I never see anything written about Medication storage and disposal in home health.  In hospice, you see a great deal of information about drug disposal after the patient has died.

I suspect that is because we have all assessed our patients are comfortable with the orders for pain meds that the MD has written.  If our 90 year old patient is in pain we do not consider the possibility of addiction when treating her pain.  What we don’t always think about is the other people who come into the house.

Here are some alarming statistics:


In this slide, shamelessly stolen off the Medscape Continuing Education activity, you see that buying drugs from a dealer is far less frequent that getting them from a friend or taking them from a relative.  The internet pharmacies that were supposed to ruin America do not make a significant contribution.

This next slide (also stolen) should make us proud.  It shows that America’s youth are more generous than Canadian youth.


What all this means is that we need to start teaching the risks of drug misappropriation to our patients.  Even though they may know their own family,there are many people who have figured out that scoring drugs from an elderly confused patient is cheaper and less risky than buying them from a dealer.   We should teach patents or assist them in putting narcotic pain relief out of sight or under lock and key.  We should teach them proper disposal of medications.  And if there is any suspicion of misappropriation, pills should be counted just as they are in the hospital or other setting.

I really encourage you to take advantage of this free continuing education from Medscape and use it in your practice.  It doesn’t take long and it may open your eyes to a threat you never considered before and allow you take action before someone gets hurt.

Plus if you take thefree continuing education activity, Medscape will be less likely to write me nasty letters for stealing their stuff.  I prefer to download the transcript but there is a video discussion for those of you who do not like to read.

By the way, don’t start talking about ‘Julianne, you know, the nurse who loves Morphine’.  It just doesn’t sound right.

Thanks, HEALTHCAREfirst!

Bobby, Deanna and Meghan
Making it Happen at HEALTHCAREfirst

Now would be a good time to offer my sincerest gratitude to my hosts last week at the HEALTHCAREfirst Conference.  I learned a lot of interesting things and met some really cool people.  The most fascinating thing that I learned is where all the Healthcare First Data is stored.  If you use Healthcare First software, you may not want to know the answer so I will leave that alone for now.

Although data storage is fascinating to be sure, I have never grown tired of hanging out with home health professionals.  I learn more from y’all than anyone will ever learn from Haydel Consulting Services.  Since I came home to a ZPIC requiring my attention, let me just briefly highlight some of the things I learned.

  1. The easiest way to protect yourself from Medical Review is to ensure that your zip code is not in Chicago.
  2. There are agencies – read carefully, Louisiana clients – that actually have average lengths of stay close to 30 days for Medicare patients.
  3. I don’t think there is a perfect place for the driving involved in home health.  Did you know that there are agencies who pay for nurses to have chains put on their tires?
  4. Hospice providers may feel a little left out at times.  I guess that is why they are receiving ADRs and other regulatory audits, at an alarming rate.  PGBA, et al, did not want them to feel neglected.
  5. The Hard Rock Café in San Antonio is a great place to watch a parade during Fiesta.

More than ever, agencies are finding their revenue vulnerable as the result of extensive and robust (that’s a computer word) regulatory review by our Payor Source.  HEALTHCAREfirst is stepping up to the plate to assist agencies in maintaining the integrity of their data.  This is a good thing for the majority of providers who want to do more than simply survive in the upcoming years of uncertainty.  But I caution you,HEALTHCAREfirst and all of their competitors sell software.  You can push any button you want on the finest computer in the world and you won’t get nursing judgment or compassion to jump out of your machine.

Having said that, a cocktail of good solid data, strong leadership and intelligent, creative nurses is a plan for an agency that will enjoy financial and clinical outcomes long after this period of scrutiny settles .

So, I learned a lot and more importantly, I met some great people.  It is really fun to meet a stranger who understands exactly what I do for a living and shares my love of the home health industry (inclusive of hospice, of course).  My own family isn’t really sure what exactly I do for a living and I am not sure that anyone who isn’t on the playing field really knows how the game is played.  So, it was fun meeting everyone and if I promised to call and you haven’t heard from me, please send an email.  I have your card under a ZPIC letter so don’t take a chance on it getting lost!

Thanks to HEALTHCAREfirst and thanks to all of their clients who made San Antonio a really fun place to hang out for a few days last week.

Finding Mr. or Ms. Right

Too often, we settle on Mr. or Ms. Right Now when it comes to hiring nurses.  This is especially of the Director of Nursing position because we are compelled to have a DON who meets requirements and to notify CMS and most states if the position is vacant and it should never be vacant for any length of time.

Ideally, most agencies have an RN already groomed for the position in their team leader positions.  For these agencies, the burden then goes to hiring the right team leaders or whatever title your agency calls these alternate RN’s in the office.

Sadly, experience only goes so far in home health.  It all depends on where the employee candidate was employed in the past.  My suggestion is that when you hire any Registered Nurse for the office, you hire them with the awareness that they may be your director one day.  After you determine that they meet al the paper qualifications, call them back in for a more in depth interview and ask some hard questions.

  1. What do you feel the biggest challenge to field nurses is at this time?
  2. If I told you that our average case mix weight is less than 1.0, what would concern  you?
  3. If the average case mix weight was 1.9, would you be concerned?
  4. Describe your idea of quality management?  What tasks do you feel are most important?
  5. In your opinion, which is more important?  Getting paperwork in on time or getting it correct?
  6. Several nurses have threatened to quit because they believe they are not paid as much as your competitor pays their nurses.  What do you do?
  7. Your patient has diabetes and arthritis.  Which is the best code to use?
  8. What are three reasons that you might get in touch with the administrator over the weekend?
  9. Describe your computer skills.   Do you use the computer only for work?  Do you enjoy social websites?  Do you use the computer a lot at home?
  10. What do you think a good average number of visits per episode should be?

There are no right or wrong answers and if a candidate is unfamiliar with the area discussed, it should not automatically disqualify them.  If you are a legitimate agency, the response to number 7 is that the best code for the patient is the one that describes the patient’s condition.  Number 8 will give you an idea of how comfortable the nurses is in taking responsibility.

The most important thing when hiring a nurse isn’t that she know all the answers.  The important thing is that you are fully aware of where her shortcomings are and that the candidate is willing to learn.   These questions will also give you an idea of the character and business sense of the potential candidate.

Agencies who use this level of scrutiny when filling all RN positions in the office are generally able to transition a current nurse into the DON position in the event of an sudden event.  This has happened to my clients numerous times over the years.  Losing a DON suddenly due to an accident or an abrupt termination is painful but it doesn’t have to be devastating if you have someone ready to assume the position.

It is so very difficult to work short handed.  It is even more difficult to work when one or more of your RN’s is not able to perform.  That’s when both clinical and financial health take a huge hit. Take the time to hire the right people.  Trust me.

Thanks to All!

I had the most wonderful opportunity to show off what we all do for a living during the last week of March.  Hugh, a reporter living in England wanted to find out how we Americans did home care and health care in general and ended up visiting with us and some of our clients.  Before he arrived, he had time in Washington and visited with NAHC members and had the opportunity to stop by the Supreme Court while the historical hearings on Healthcare Reform were ongoing.  Having never paid a physician bill or an insurance premium, he had to have been bewildered at all the commotion.

Upon arriving down south, he got to meet some of my colleagues, coworkers, and coworkers.  Ray Banker, Demetrix Tolliver and Lorraine Wells all visited from local agencies.  Jnon Griffin of Comfort Care in Alabama came to represent fans of the Red Tide.  Poor dear.  In case you think the South was overrepresented, keep in mind that Bobby Robertson from Healthcare First visited as well.  His clients are spread out across the nation and he has unusually keen insights into our industry.

Ray Banker of Audubon Home Health made a big deal about having tickets to the hospital’s annual fund raiser which was featuring the 80’s band, Foreigner as the entertainment.  He pointed out several times that there were no remaining tickets left so even if we wanted to go, we would not be able.  I enjoyed the picture of Hugh with the band at the hotel bar later that evening more than a well balanced person should.

So, yes, I am grateful to all.  My visitor learned more than he ever wanted to and we learned a lot from  him as well.  (As an aside, this man who has never paid a physician bill or health insurance premium comes from a country where only 8 cents of each dollar is spent on healthcare as opposed to 15 cents in the US.)

The fun part came later.  Imagine if you were from another country where it is cold (by our standards) and rainy all the time.  You fly into the states and hang out at the Supreme Court and NAHC and then arrive in the South and experience Southerners – US -for the first time.

Imagine that you have never seen a bayou, eaten a crawfish, touched an alligator or met a Katrina survivor.  Thanks to Tory at Bayou Health Care, that is exactly what happened on Thursday.  That’s a pretty big day by any standards.

The Katrina refugee was actually a patient with Medicare and one of those Medicare gold advantage plans.  After falling off a ladder and breaking is pelvis, he was sent home at two am in what can only be described as frank, abject, maybe horrifying pain.   Technically the pain only occurred when he moved but it was difficult to get him out of the car and into the bed without moving him.  He is very lucky he is not married to me or he would still be in the car with his bottled water and his urinal.     He was instructed to go to the MD within five days but couldn’t because his wife couldn’t handle the enormous task because of Multiple Sclerosis.  Tori was working on it and a visit was scheduled to occur the day after we left – closer to 30 days after the fall.

Then we saw the alligators.  I thought they were so friendly because they were cold but maybe not.  Our guest noticed bullet hole in the head of one which completely dispels my illusion that the gators just liked me.  Doesn’t that say volumes about my assessment skills?

Apparently there is a television show called Swamp People filmed in Pierre Part.  We met several family members but ‘Troy’ was out getting some crawfish so we browsed the gas station in front of the Alligator fridge but none of us purchased  a ‘Choot ‘em’ tee shirt.  I feel sort of bad for the relatives of tourists bringing these home to family and friends in places where ‘Choot ‘em’ is not  the phrase used to describe the act of discharging a weapon. They must think the Tee Shirts were discounted because of a screen print error.

I don’t eat crawfish unless it comes with a cocktail made from benadryl, solumedrol and epineprine which wasn’t on the menu at Landry’s but Mandy is a pro at teaching others how to eat crawfish.  We are currently applying for Continuing Education credit for the course but so far have had a lot of documents thrown back at us for ‘clarification’.  See photo.  How could anyone need further clarification.

We stopped briefly at the Virgin Island – singular; not to be confused with the string of islands in the West Indies – to show Hugh snakes and turtles which are not common in England, apparently.  He started getting a little anxious and wondered how he was going to explain away this 10 minute side trip as work.  After I figured out that he was serious, I clued him in.  This was home health.  We don’t always stop to pet the gators but they were right there at the gas station anyway.  Our Katrina victim and Medicare patient may have seen a bit extreme but all of our patients have unique histories and challenges.  And in South Louisiana, there are only so many days when you actually want to get out of an air conditioned car so we took advantage after driving all day.

So our reporter will have many political twists and turns that affect our industry and be able to write with confidence about the National Association as they rallied – yet again – for a targeted approach to fraud and abuse.  The grandeur of the US Supreme Court in the midst of three days of historical hearings on health care reform is decidedly noteworthy.  But down the bayou, (or in the high rise, the mountains or the inner city) is where the patients can be found and wherever there are patients, you will find good nurses.

This is who we are – nurses taking care of people in their homes in the face of enormous challenges that have never been considered in Washington.  Home health isn’t about politics or fraud and abuse.  It is about finding a ride for a patient to get to the doctor.  It’s about holding the hand of someone with a new diagnosis of cancer or trying to get the multi-pill jar patients seem to prefer sorted out.  Its about teaching complicated medications to patients who really just want to get better and don’t care about anion gaps and insulin resistance.  It is also about being a part of a community that may or may not include alligators and snakes, highrise buildings with unreliable elevators, icy mountain roads or too many narrow alleys roped off as crime scenes.

Seems to me that if a reporter from another continent can take the time out of his life to ride down the bayou visit patients, so can the politicians and lobbyists who believe they know what is best for the Katrina refugee who relocated after the storm and can’t get to the doctor in this family oriented community where he has no family.    I wish the Supreme Court Justices would ask  Tory what she thinks of the individual mandate.  And I am very open to taking Kathleen Sebelius for a ride down the Bayou.  If anyone sees her, tell her to give me a call.

Special thanks to my happiness engineer at WordPress.  I tried to upgrade some services when my domain expired and what I wanted to do wasn’t possible.  As it got later and later and my frustration grew, I emailed the support crew.  Elizabeth, my happiness engineer didn’t just send me complicated instructions; she took care of the complicated domain mapping and such.  I wish there were more happiness engineers in the world.

How to Reduce Hospitalizations

First of coumadinall, I am getting some really good information from the Medicare 101 quiz posted Sunday evening.  When the responses stop coming in, I will share some of the more interesting results with you.  It will certainly give us some useful information to use when writing posts in the future.

As I suspected, Coumadin should be a schedule II medication controlled to the same degree as Oxycontin and other medications that shouldn’t be distributed freely due to the risk of untoward side effects up to and including death.  Now, I have proof.  Medscape has a new, very short CE activity that offers evidence to support my position.

After reading the CE article, I am sure you will agree with me that the best way to prevent unavoidable hospitalizations is to discontinue Coumadin on all of your patients.  Seriously, if I was an ambulance chasing lawyer, I wouldn’t spend money on TV commercials for my law practice. I would advertise Coumadin.  If your stodgy MD’s don’t agree with my assessment, at least consider upgrading your communication processes related to Coumadin.

(By the way, in case you think Pradaxa is the answer, you may want to rethink your position.  Four days ago, the FDA issued this warning about Pradaxa.  I only skimmed through it but I believe it said something about post marketing reports of bleeding putting the patient at risk for hospitalization or even death.   That is never good and almost always messy.)

So I guess that leaves us with good old fashioned nursing care as a solution.  Consider using SBAR-C communication when communicating with others about Coumadin.

    • S – Situation
    • B – Background
    • A – Assessment
    • R – Recommendation
    • C- Communication


Situation:  I just drew lab on Ms Smith as ordered a week past her last dosage change of Coumadin.  She is currently on 7.5 mg daily and her INR is now 4.2.

Background:  She had a mechanical valve replacement two years ago and did fine on her Coumadin until recently.  Her INR’s decreased to sub-therapeutic in recent months.  Her two most recent INR’s and corresponding dosage changes are: (give example).

Assessment:  She has no signs of external or internal bleeding.  (give vital signs)

Recommendation:  Do you want me to hold Coumadin for a couple of days and then restart?  If so, what do you want her dosage to be?

Communication:  Gave above orders to JUDY, patient’s daughter who stated she was removing the Coumadin from the patient’s med planner box now and putting the bottle of Medicine on top of the refrigerator so it wouldn’t be mixed up with normal meds.

All of these steps are important but detailed communication of orders is the most frequently missed step.  It is also the step that could get you into serious trouble if the patient ends up in the hospital with a bleed to the brain.  Documenting that you told the patient’s daughter is all well and good if she only has one.  It is always best to document the name of the person you told and the time and date of the phone call.  Details lend credibility.  (And details are always easier to provide if you document contemporaneously with your work but that is a subject for another post.)

Sometimes, there is nobody reliable to instruct on changes.  In that case, an additional skilled nurse visit should be ordered so the nurse can go to the house and remove the Coumadin herself.  Since we know that unstable Coumadin patients are going to have a lot of unanticipated lab and orders, conservative scheduling with PRN orders for medication updates should accommodate the needs of the patient without breaking your budget.

Or, you can go back to my original advice and discontinue Coumadin on all of your patients but before you do that, let me explore some of the regulatory issues that may arise if you don’t follow physician orders.  I seem to remember reading something about that somewhereSmile.

%d bloggers like this: