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Walmart Humana Merger


While nurses like us and other clinicians have been worrying about patient care, documentation and the new CoPs, Walmart and Humana have been getting cozy in the back room working out the details of yet another mega-deal.

The idea has an upside. A full 90 percent of Americans live within 15 minutes of a Walmart. That could go a long way to eliminating any access to care problems. Walmart’s drug prices are often less than competitors’ and could possibly be lower if they were the preferred pharmacy for Humana. Folks could see a physician or nurse practitioner, ask that their scripts be electronically sent to the pharmacy to be filled and go shop for everything from an oil filter for their car to Roma tomatoes while they wait- how convenient.

This sounds so good that maybe the good people involved in this potential deal are blind to the downside. Or, maybe they have never been to a Walmart.

Why do you go to Walmart? I go because stuff costs less. I do not expect sales associates to ask if I need help or because they play catchy background music. I dont expect anyone to help me pair cheese and fruit although to be honest, Kraft singles go with just about anything. I go to Walmart because stuff is cheap and in return, I lower my quality expectations. Have you ever compared a Walmart T-shirt to one from The Gap? Gap T-shirt’s make me happy. I would have to be sedated if I found a better T-shirt.

Walmart employees tend to be good people but the retail giant’s recruiting strategy is putting a computer in a conspicuous spot in the store to interview prospective employees. There is rarely just one person answering the questions so they must be hard.  To be fair, Walmart offers mostly entry level positions – starter jobs. I have never worked for Google or Microsoft but I don’t think this is how they filter through countless applicants.

I have to ask myself if this is the approach they will take to hiring the health care professionals that staff the Walmart and Humana clinics. ‘Our Mediocre doctors and nurses are the backbone of our clinic’, their tagline might read. ‘We’ve lowered our standards so you can pay less’. Do you want a mediocre practitioner in a starter job taking care of your child or grandmother?

And if someone has the flu, a standard script (computer generated from Humana’s algorithm) is probably all that’s needed for a patient who will spend the next 45 minutes infecting everyone else in the store. Watch as Walmart clinics go viral. Literally.

When flu season comes to a halt, things get trickier. As a recovering Walmart shopper, I am confident when I say that pretty much every one in the store is a potential patient. Unlike Whole Foods where you may run into your Yoga friends wearing yoga pants, the Walmart shoppers squeezed into a Spandex Lycra blend are not practiced in the art of Ashtanga.

And Walmart goes out of their way to perpetuate an endless supply of patients. Ramen noodles sell for a dime a piece but it is cost prohibitive for low income families of four to eat a meal including boneless, skinless chicken breasts. Red beans and rice, a perfect protein thats easily affordable always has directions to add sausage which enhances the flavor as much as it plumps up those thighs. The cheap high fructose corn syrup disguised as fruit juice costs only a fraction of the price of the real stuff. In the South where Roman Catholic values prevail, grocery bills rise each time a sibling is added and these low prices are appealing even if they kill folks eventually.

What happens if one of the Walmart shoppers/victims with a history of eating on the Walmart plan

falls out in the store? Can you see the utter chaos as the mediocre care practitioners try to read their CPR pocket card and perform chest compressions simultaneously? How many potential patients will remain loyal to Humana after they see a patient die because, after 22 attempts, there were no more IV catheters left in the crash cart and emergency drugs could not be administered.

If this deal goes through, it will be a failure for everyone involved. Humana may save money on drugs but by the end of a year, Blue Cross will emerge as the premiere insurance carrier by default. Physicians and Nurse Practitioners with restricted licenses rendering mediocre care may be an effective cost savings approach but without being surrounded by competent colleagues who can teach them or at least watch their backs, million dollar payouts will become the norm.  After all, there will be a lot of witnesses.

Walmart needs to spend their cash on improving the experience of their employees and Humana might think about increasing the speed of paying claims. And I need to be able to sleep without worrying about receiving Walmart branded healthcare.

But the most important reason to speak out against this deal is because it is nothing more than business – a way to make money.  They could have respected us enough to at least pretend they were aiming to meet needs of the people who made them successful in the first place.

Your thoughts?

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.

More Conditions of Participation


484.55 Condition of participation: Comprehensive assessment of patients.

Most agencies will not find it difficult to comply with the requirements in the Comprehensive Assessment because they are already assessing these areas.  The fact that ‘Cognitive Status’ which is already included in the OASIS data set and ‘Patient Goals’ are now mentioned in the Conditions of Participation may be an indicator of exactly how serious Medicare is about changing their focus to a patient centered approach to care and outcomes as opposed to the more punitive approach of hunting for agencies that disregard regulations.

The biggest change regarding the Initial Assessment that I see is that the Occupational Therapist is now able to complete the initial visit if OT is the only service ordered by the MD and if the need for OT establishes Medicare Eligibility.  Welcome to the world of Admits, OT’s.

Content of Comprehensive Assessment

  • Current health; functional and cognitive status
  • strengths, goals and care preferences
  • Continuing need for home care
  • Review of all medications (Identify potential adverse reactions, ineffective drug therapy, side effects, significant drug reactions, duplication and noncompliance with meds.
  • Patients primary caregiver and other available support
    • Willingness to provide care
    • Availability and schedules
    • Patients representative if any
  • Incorporation of OASIS data

Recertification visits are still done within the same time frame (days 56 through 60 of episode).  Resumption of care visits are done within 48 hours of the patient’s return to home OR on physician ordered ROC date.

Plan of Care

Patients are accepted for treatment on the reasonable expectation that the agency can meet medical, nursing, rehab and social needs in the home.  Care plan must specify the care and services to meet specific needs identified in the comprehensive assessment.

Plan of Care contents

  • All pertinent diagnoses
  • Mental, psychosocial and cognitive status
  • Types of services, supplies and equipment required
  • Frequency and duration of visits to be made
  • Prognosis
  • Rehab potential
  • Functional limitations
  • Activities permitted
  • Nutritional requirements
  • All Medications and Treatments
  • Safety Measures
  • Risk for Emergency dept visits and rehospitalizations
  • Measures to mitigate risk of above
  • Patient and caregiver education
  • Specific interventions and education
  • Measurable outcomes and goals mutually identified by the patient and agency
  • Advance directives
  • All orders

Each patient must receive a copy of their plan of care.

Additionally, each patient is to receive written instructions that include:

  • Visit schedule
  • Med list with names, dosages and any meds to be administered by agency
  • Any treatments including those administered by agency or persons acting on behalf of agency including therapy.
  • Any other pertinent instructions specific to the patient’s care needs
  • Name and contact information of the agency clinical manager.

Revision of POC

There is nothing new here but something has been removed.  There is no requirement that a 60 day summary be sent to the physician.  It shouldn’t be needed if agencies abide by the following.

  • The plan of care must be reviewed and revised by the physician responsible for the home health plan of care at least every 60 days .
  • Agency MUST promptly alert relevant physicians to any changes in the patient condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.
  • Revised plan must reflect current information from updated OASIS and contain information about progress to goals.
  • Revisions must be communicated to the patient, representative (if any), caregiver and all physicians issuing orders for the plan of care.
  • Revisions related to discharge planning must be communicated with all of the above plus the patient’s primary care practitioner or other healthcare professional who be providing care for the patient in the community.

Conformance with MD Orders

  • Drugs, services and treatments are administered only upon the order of a physician.
  • Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, and after assessing for contraindications.

Actions:

  • Review the way your agency handles plans of care and ensure your process includes a mechanism for dissemination of information to all physicians writing orders for a patient.  Review or develop a vaccine policy that allows for administration of flu and pneumonia vaccines according to a well-written protocol developed in conjunction with a physician.
  • Most agencies will have to expand the collection of information related to caregivers and availability.
  • Begin now to audit admissions for the requirements set forth in the CoPs.
  • Begin reviewing admissions using a tool based on the new requirements.  admission-review-tool.pdf  Modify to fit the needs of your agency.
  • Educate your staff.

More Later.  And to think, we haven’t even looked at Quality Assurance, yet.

PEPPER Reports


What if I could tell you how likely you are to find your agency under intense scrutiny by Medicare?  Would you want to know?  What if I could tell you what Medicare expects you to do to address any risk areas?  Would you do it?

Chances are the answer is a resounding, ‘No!’

You can have all this information within 15 minutes.  All you need is your provider number and a patient ID number for a claim that has been paid prior to July 17, 2016.  Both of these numbers are available on any 485.

Using these two numbers, any Medicare certified home health care agency can access the PEPPER portal.  There you will find your agency specific reports that show where an agency falls compared to other agencies in areas that Medicare has identified as those being closely associated with Medicare fraud and abuse.  Of all certified home health agencies, only 20 percent nationwide have bothered to look at their data.

One nurse asked me if maybe it was better not to download reports.  Her rationale was that if Medicare would come down harder if they believed the agency was aware of any high risk areas as opposed to being unaware.  To be clear, Medicare is not going to cut you a break if you didn’t know that your agency was meeting the threshold for any of the target groups reported.

Here’s what the PEPPER reports show:

Average Case Mix

Agencies with an average rate of 1.6 or higher may find themselves looked at for possible up-coding.

Average Number of Episodes    

Nationwide, agencies in the 80th percentile provide an average of 2.78 episodes.  Medicare believes there is a high chance of improper payments if you meet or exceed an average of 2.78 episodes per patient.

5 or 6 Visits                                       

In order to get paid the full amount for an episode, an agency must provide at least five visits.  Any nursing care over and above five visits adds to the cost of the episode but not to the payment.  If your agency has more than 7.2 percent of their episodes with five or six visits, Medicare believes there is a chance that you are maximizing income without regard to patient care.

Non-Lupa Payments                      

Medicare expects that agencies will have LUPA payments.  When the number of LUPA payments is very low, Medicare suspects that an agency is avoiding LUPA costs by providing unnecessary visits to qualify for full payment.

High Therapy                                    

Although some patients require 20 or more therapy visits per episode, the assumption is that agencies in which 2.9 percent or more of patients required 20 or more visits may be adding unnecessary visits to capitalize on the enhanced payment associated with high therapy.

Outliers                                              

The target for outliers is 7.6 of total payment.  Note that this is less than 7.6 of total episodes.   Anything over 10 percent will be adjusted quarterly.

These indicators of possible improper payments are only data.  It is possible to hit the target in one more areas without doing anything improper.  However, a prudent agency will be well aware of where they fall and document accordingly.  Should questions arise, the agency should be able to provide an explanation as to the aberrancy.  If you cannot arrive at a suitable answer, take a long and hard look at your charts.

The PEPPER reports that have been shared with us do not approach any level of concern.  (Fraudulent agencies often eschew our services which focus on compliance.)  My guess is that PEPPER Reports are effective at identifying improper payments.  Agencies that routinely provide three episodes per patient and all the episodes have exactly 6 visits may not be assessing the patient and meeting their individual needs.   If you are employed by an agency that has hit multiple targets and seems disinterested in addressing them, you may want to reconsider your current employment status.

If you decide to download your PEPPER reports, please let us know.  If you feel like sharing them, we’d love to see them and promise to keep them confidential.

Making Time


It’s lonely being a Director of Nursing – doubly so when the agency Administrator is not a nurse.

There are subtle differences between states on the responsibilities of the Director of Nursing but together with the Clinical Supervisor’s role outlined in the Conditions of Participation, it is clear that a DON is responsible for almost everything that happens in a 200-mile radius.  These responsibilities include but are NOT limited to:

  • Oversight of all clinical personnel and all clinical services
  • Making sure that all patients have care plans
  • Patient Assignments
  • Developing and overseeing clinical policies and procedures
  • Infection Control
  • Quality Assurance
  • Staff education
  • Compliance
  • Hiring staff
  • Ensuring that all admission procedures are followed

That’s a pretty daunting list so I hesitate to say it is incomplete but… it is.  Although the tasks can be delegated the responsibility belongs to the DON alone.  Going to a non-clinical administrator about infection control or required education for staff may be a fun way to spend an afternoon but the surveyors will look to the DON for answers.

Before you quit your job and punch yourself in the face for accepting the responsibilities of the DON position, relax.  It can be handled and is handled every day by nurses who are no more skilled than you.

Like most overwhelming jobs, the position of DON is easier when broken down into smaller pieces.  It is also easier if you identify all the impediments to doing your job well before you try to do it better.

Time Management

  • Open Door Policy – this sounds really good in company sound bites and recruiting campaigns but an open door policy can wreak havoc on your day. Instead, hold office hours like college professors do.  This doesn’t mean that nurses cannot interrupt your day for urgent matters but all non-urgent matters should be conducted during office hours.  During office hours, your visitors should have your full undivided attention.  If you want to make notes, wait until after they leave and write down your thoughts while still fresh in your head.
  • Meetings – Meetings are important but after a point, they become time-wasters. Eliminate all meetings that are not necessary and be prepared for necessary meetings.  Meetings should start on time.  Invite participants to arrive a few minutes early if they want to visit with coworkers.  Clinicians who are unprepared at case conference will be obvious.  Don’t rescue them.  After they flounder in front of their peers once or twice, they will be able to fully participate.  Or not.  If an adult cannot be responsible and prepared for meetings, maybe you should rethink their position in your company.
  • Delegation – most tasks of the DON can be delegated. Delegation consists of two parts – one is assigning the task and the other is the oft forgotten follow up.  Survey is a very bad time to find out that a nurse performing utilization review did not understand the process.   Send yourself an email to follow-up on an assignment you delegated.  Was a nurse tasked with collecting data for infection control?  Write it on your calendar to check in with the nurse in a month.  Look at the work done.  This takes a lot less time than trying to recreate data during a survey.   Taking the time to schedule QA, OASIS transmission, annual advisory board meetings and other infrequent but mandated events will reap an enormous return on investment.
  • Set aside some time each day when the phone does not ring in your office. Have the receptionist screen the calls and take messages.  Only take calls from patients who cannot be helped by their nurse, and referral sources.  When this policy was implemented at one agency, about half of all phone calls were handled before they got to the DON.

Hiring Process

 Learn how to interview potential candidates for a job. Listen to what they have to say.  Monster. com has a list of the 100 Most Asked Job Interview Questions. Consider asking candidates to teach you about falls precautions or injecting insulin as if you were a patient.  (Note:  do not ask about what kind of care they drive as suggested on Monster.  Ask what kind of car they dream about owning.  Avoid candidates who name a grey sedan.)

  • Schedule all interviews on the same day and set a mental timer to reduce the amount of time you spend on each interview.
  • In larger agencies, consider deferring the initial interview to a case manager who will be the direct supervisor of the new employee.
  • In all agencies, schedule a second interview that includes various people the candidate will work with on a daily basis. Your current staff is more likely to support a new employee if they endorsed the initial hire.

Staff Education

  • Get someone else to provide education to your staff. Call on drug reps to teach your staff about new and trendy drugs.    Get the wound care folks to teach about wounds.
  • Involve staff by assigning a five to ten-minute presentation on compliant documentation, a new drug or a condition not seen very often in your area to begin each case conference. (Note:  You can start to identify the next case managers or even your replacement by observing how well prepared they are and how comfortable they are talking to their peers.)

Perks of Managers

Setting up your work environment to allow for focus and completion of the tasks and follow-up on coworker’s projects will leave you feeling accomplished. Your stress level will automatically decrease as deadlines are no longer looming over you.  Your ability to trust your staff will improve when you follow-up up on their projects allowing you to appreciate the support you have.   Most importantly, you’ll get home in time for dinner with the fam.

Got any other ideas?  Post in comments!

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