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Posts from the ‘Home Health Nursing’ Category

Five Steps to Improved Documentation


 

Paperwork is part of the job. Next to patient care, it is the most important part of your job. Wouldn’t it be nice to see your patients and document well in time to don your pearls and cook dinner for your family? Or maybe you just want a cocktail or two while you watch the evening news. Pretty much nobody wants to stay up until midnight documenting so that they can be paid on time.

  1. Turn off the Cut and Paste function. There are some clinicians who should have a neon sign on their forehead reading, ‘I document. Therefore I clone.’ Turn it off. If you survived nursing school or have an advanced degree in therapy, it stands to reason that you can compose an original note without copying the prior note.
  2. Write plans of care that address the patient’s issues. No more. No less. If there are two or three pages of orders, the important stuff will be buried in the minutia.
  3. Read the care plan. That sounds obvious but nurses cannot read care plans if they aren’t present and in the chart. This should be a priority and nurses should refuse to see the patient if they do not have one. At the very least, a verbal report from the admitting or recertifying nurse should be given and documented. It is easy to lower the bar on this but very difficult to raise it. But we are nurses. We do difficult things and we need care plans.
  4. Payment is often in the details. If you are not in a position to document in the house, keep a pocket sized notebook with you and write vitals and what was taught.
    1. Weights
    2. Blood pressures
    3. Pain
    4. Heart rate
    5. MD visits
    6. Medications
    7. MD and hospital documentation
  5. Teach only useful information that your patient can understand. The internet has no shortage of teaching guides available from the web. Look for teaching guides that have been published by reputable organizations such as the American Diabetes Association, the CDC, the National Institute of Health and University hospitals. That way, if the information is bad, you can at least credit a reputable source. Upload this information into the computer in the patient’s electronic record. Then you can chart, ‘reviewed pages 1 – 4 of DM teaching guide and taught page 5’. And remember that teaching guides should vary according to the patient’s needs.
  6. Complete a short pre-visit checklist the day before your visit that includes calling your patient to confirm the visit, ensuring that appropriate teaching guides are uploaded and available in printed format for the patient, determining if there are additional orders since your last visit and read any documentation that another clinician submitted. This will ensure that you are able to give the best care possible to your patient.

Although going through these steps may seem like more work, it isn’t. Consider driving 15 miles to a patient’s home only to discover they had an MD appointment. If you are unprepared for teaching, you may waste your time and the patient’s. Reconstructing notes and trying to remember vital signs is a task that is slightly less pleasant than a root canal and takes time. Doing the job right the first time saves so many headaches that the manufacturer of Advil would be in jeopardy if everybody bought into the concept

Perhaps the greatest delay in documentation is finding better things to do. It requires discipline to complete quality paperwork within 24 hours of a visit. It is a habit you need if you are to be in home health longer than a week.  Believe it or not, there is an app for that. Actually, there are fifteen apps for that. Try one. Because although clean documentation that doesn’t boomerang back to you and is submitted on time gets the agency paid, the effect on your life will be even more amazing.

Work Place Violence (and free CE’s)


workplaceviolence_bannerI must say that everyone is pretty good about conducting a home safety assessment. Throw rugs are removed, lights are bright and shiny and and much of the work done by therapists is to reach the goal of the patient being able to safely navigate in the home environment. Geaux, Team!

We’re missing something. What about employee safety in the work environment? Everyday home health and hospice nurses, aides, MSW’s and social workers go into homes where they are separated from the agency and out of view of anyone who might help them. All but the most serious incidents are overlooked.

In addition to the injuries that happen regularly such as sprains, abrasions and other musculoskeletal injuries due to moving patients, these are routinely addressed in orientation and annual inservices. A risk of workplace violence also exists and recent research shows it is more prevalent than you may think.

Homecare workers (n = 1,214) reported past-year incidents of verbal aggression (50.3% of respondents), workplace aggression (26.9%), workplace violence (23.6%), sexual harassment (25.7%), and sexual aggression (12.8%). Exposure was associated with greater stress (p < .001), depression (p < .001), sleep problems (p < .001), and burnout (p < .001). Confidence in addressing workplace aggression buffered homecare workers against negative work and health outcomes.1

The CDC along with NIOSH has published an online Continuing Education course addressing workplace violence for healthcare workers. It is not specific to visiting nurses but does offer useful advice. It also offers 2.4 continuing education credit but if you want the credit, read the ‘instructions for credit on the first page. It is provided at no cost and includes short video clips, written text and discussion questions.

In taking this course, I learned that when adhering to the strict definitions of Workplace Violence, many homecare workers have experience with verbal and physical aggression. We also under report workplace violence and ‘forgive’ our patients. It may be a fact of life that nurses eat their young but it doesn’t have to be and agencies should not tolerate bullying of their employees. Regardless of the kind of workplace violence that takes place, visiting staff may suffer stress, depression, insomnia and burnout as noted in the study cited above. Without support from management, the agency’s morale will deteriorate to the point where nothing gets done.

If you know of any other resources to reduce the risk of workplace violence in the workplace, please share in the comments. Our workplace includes most zip codes in the country and all types of people. Reducing the risk of violence and supporting visiting workers can go a long way to making sure you’re agency doesn’t lose its best employees to burnout.

  1.  Hanson, G. C., Perrin, N. A., Moss, H., Laharnar, N., & Glass, N. (2015). Workplace violence against homecare workers and its relationship with workers health outcomes: a cross-sectional study. BMC Public Health, 15, 11. http://doi.org/10.1186/s12889-014-1340-7

Suicide Contagion


Every time a celebrity commits suicide, we pay attention to Depression and the tragic end outcome if Depression is not treated or does not respond to treatment; at least for a little while.

I have never owned a Kate Spade purse but I liked her. Together with her husband, they created a brand that took whimsy seriously and added color to our world.

Anthony Bourdain lived the life of my dreams; travel, adventure and food. Could there be more?

Neither Kate Spade or Anthony Bourdain allowed their public personas to reflect the extent of their illness. This is understandable in terms of privacy but leaves many people shaking their heads because they can’t understand how celebrities who appear to have everything would choose to die.

Home healthcare patients are confined to their homes. Some have lost one or more spouses and may be separated from family who have moved to pursue careers. They are sick and many are in pain. Their outward presentation is that of a patient population at high risk for depression.

As it turns out, 20 percent of people over 65 are depressed and men in their 80’s have highest rate of suicide of all age groups.  Across the board, the rate of suicide is rising as funding for mental health is declining.

Suicide prevalence image

As of last week, patients are at an even greater risk for suicide due to the phenomenon of Suicide Contagion which is exactly what it sounds like.  Suicides occur in clusters almost appearing to be contagious like a virus.  In the four months after the loss of Robin Williams, the overall suicide rate increased by 10 percent. Google searches for suicide related topics increased after Netflix aired ‘13 Reasons Why’. There was a 25 percent increase in the number of calls to the National Suicide Prevention hotline in the two days following Anthony Bourdain’s death.

One reason has been attributed to journalism standards. There are journalistic guidelines for reporting suicides that nobody seems to follow. Near the top of the list is not reporting on the details of suicide.   When reporting on a suicide, the WHO also recommends including information on how to get help. Most initial reports of last week’s high profile deaths included this information – usually at the end of an article that might be missed – but as the days progressed, more attention was given to the ‘gossip’ and a few interesting conspiracy theories surrounding these stories.

But we’re not journalists so how does this pertain to nursing.  How many of your patients spend most of their waking hours tuned to the television news?  Depending on the reporter or news station, some news stories are almost like a tutorial or at best a psychological autopsy that is really none of our business.  Most nurses also have social media accounts.  Think twice before sharing or reposting a story that has sensational or dramatic headlines.

What should you do for your patients?

  • Regardless of prior diagnoses or risk factors, encourage your patient to do something other than consume the details of tragic suicides. You might investigate alternative viewing options, suggest some time outdoors, a book or a crossword.
  • Pay attention to your PHQ2 assessments. I am incredulous when reading about patients who start their day with a round of golf and end it with their chest opened with power tools due to a cardiac event. Three days later they are admitted to home healthcare and report zero days with little interest or pleasure of doing things or feeling down. A positive PHQ2 does not confirm a diagnosis of depression but it gives you a baseline and together with the physician, you can look at medication side effects, ensure the patient is able to sleep and address pain. If the patient doesn’t show improvement in two weeks, there is a strong possibility that he or she won’t participate in their plan of care to the extent that they can which will prolong healing and further treatment may be indicated.
  • If your patient is pre-loaded with a diagnosis of Depression and is on medication, take it from there. Don’t just assume it has been handled.  Teach side effects of meds, encourage socialization, educate the family, etc. Never assume that a med is going to work completely and consistently. After all, diabetic patients aren’t started on metformin and never checked again.
  • Talk about depression in the same tone that you talk about other diagnoses. Depression is seen by many from former generations as a weakness. Assure your patient that depression is an illness and is not a reflection on their character or inner strength.
  • Leave written information adjusted for the reading level and visual acuity of your patient about resources they can access if symptoms worsen. Put the information in a place that is obvious to the patient and near the phone.

Depression is not a normal part of aging. You can implement measures to improve your patient’s depression and dramatically improve the quality of their life. With mental health funding dwindling across the nation, we need to up our game.

Other Resources

Men and Depression – low literacy

Depression in the Elderly – low literacy

CDC Suicide Prevention Fact Sheet

UPIC


I admit that I was a little hopeful, if not disillusioned, when the new UPICs came to my attention.  After verifying that UPIC was not a ZPIC with a typo, I thought that maybe this was a special type of audit where you got to pick the charts you wanted to be reviewed like some people pick their own lottery numbers.  No such luck, I’m afraid.

UPICs are Unified Program Integrity Contractors.  UPICs will carry out program integrity functions for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, and Supplies, Home Health and Hospice, Medicaid and Medicare-Medicaid data matching[i].  The primary objective of the UPIC is to identify fraud and abuse and make appropriate referrals.  Other agencies recoup overpayment and address recommendations to law enforcement addressing criminal or civil charges.  They can also recommend suspension of payment.  Whether or not the agency is notified in advance of the payment suspension depends on if the UPIC thinks it is possible that the provider will change it’s billing habits if it knows that payment will stop.  Think about that for a minute.  Who wouldn’t change their billing habits if they knew payment was coming to an abrupt halt?

UPICs, like ZPICs can request clinical records, verification of licensure, copies of claims, etc.  The most recent UPIC request I read included a host of new horrors that may not be available and/or are too cumbersome to send.   Here’s a short recap of some of the new things but remember, they can always ask for more or even go to your office to visit.

  1. Copy of the face sheet. I have never used this term in home health or hospice, but it is basically patient demographics and insurance information.  People who have experience in a hospital are likely familiar with this term.
  2. Copy of Medicare card and state identification card (driver’s license or state ID). The logistics of getting a copy of the Medicare card and state identification card involve too many opportunities for loss and theft that I don’t recommend it even if Medicare wants it.  However, Medicare and other payor sources lose money daily when somebody loans (rents) their Medicare/Medicaid card to someone else.  Some software systems allow you to post a picture of the patient on the face sheet.  DNA and fingerprints are not necessary, but the end of the earth is not too far to go if there are any doubts. 
  3. Authorization of benefits. This is almost universally included in the consent form given to patients.  Take a quick look and ensure that somewhere on the consent it says that the patient or representative authorizes the agency to bill Medicare for services.  It would hurt a lot if this statement was inadvertently omitted when all those changes were made to the form relative to the new Conditions of Participation.
  4. EHR Audit Trails. In most systems, these audit trails are cumbersome to obtain and require someone to print or save the audit trail for each individual document.  In one system, the audit trail can be over 100 pages for a single document.  For a long time, there was a vendor who provided audit trails on request, but the agencies were not able to run them.  If you get a UPIC, consider the burden to your agency and call the person who signed your UPIC letter.  It kind of makes paper charts seem appealing again.
  5. OASIS to include the start of care, the resumption of care certification prior to and after the dates of services noted in this request and the discharge. I’m not entirely sure what this means.  To the best of my knowledge, patients aren’t certified after Resumption of Care unless the patient was in the hospital at the end of the episode and there is no change between the recertification assessment (not mentioned) and the ROC HIPPS code.  If an agency has a reasonable hospitalization rate, this is a rare occurrence.  Plus, there are numerous other bullets in the list that mention OASIS assessments.
  6. Travel Logs. Some agencies don’t have travel logs.  Some don’t pay mileage and others pay a flat ‘trip fee’.  I would think a visit log would be more useful to the UPIC but in the two page request, that wasn’t mentioned.

There are many more entries in the UPIC request but even though the length of the list is daunting, it is repetitive.  Laboratory results are requested on page one and all diagnostic tests are requested on page two.  There are individual entries for all hospital documentation, Inpatient records, Inpatient records to support start of care, inpatient records for hospitalizations during the episode, emergency room visit notes and the history and physical.  The best advice I can give is to be careful when delegating the tasks on the list, so you don’t have multiple employees all printing OASIS assessments.

The good new is that most of you will not find yourself in the undesirable position of being the target of a UPIC. If you are one of the unlucky ones, well, it’s not luck that brought you the unwanted attention from a UPIC.  The data analytics are very sophisticated and there is nothing random about the selection of charts (which makes me wonder why a copy of your Medicare Census is included in the list of documents required from the agency.  They know who your patients are.)

That doesn’t mean that your agency is operating outside of coverage guidelines.  It does mean that cloned notes, poor coding, lack of OASIS skills and care plans that are copied from one episode to the next will be under the spotlight.  This results in paying money back to Medicare and additional scrutiny which may extend to your referring physicians who might then begin referring patients to your competitors because they don’t like attention from Medicare any more than the rest of you do.  I do not like it when care is provided to eligible beneficiaries gets denied because a nurse is a little too eager to show off his or her new cut and paste skills.  It’s not like the agency can recoup their paychecks.

Questions?  Comments?  Do you have any experience with UPICs?  Post your comments below or email us.  We need to know now so we can understand them before they become obsolete.

[i] From Noridian Healthcare Solutions

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?

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