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Posts from the ‘Home Health Nursing’ Category

Bad Blood


I know Elizabeth Holmes. Chances are you do, too.

I have never met her or spoken with her but I recognize her. I see some former clients in the pages of John Carreyrou’s, Bad Blood: Secrets and Lies in a Silicon Valley Startup. Holmes has the distinction of being the youngest female billionaire but fraud evens out the playing field. Right now she is worth about nothing and Theranos, her company, is but a memory.

Theranos was going to revolutionize the lab industry with a device that would run over a hundred lab tests with blood from a single fingerstick.

My first thought was who needs that much information?

It doesn’t matter who needed it because it never worked. In order to use the blood, the sample had to be diluted and that never turns out well when there are tiny variations in concentrations of very little blood causing major deviations in results.

Reading Carreyrou’s book was like reading a clinical record of a psych patient without authorization. Elizabeth Holmes had but a passing acquaintance with the truth and it’s anybody’s guess where her fantasies stopped and her lies began.

It helped that she was very well connected. Her board of directors could take down small countries before lunch just for fun. Henry Kissinger, George Schultz, Sam Nunn and more believed in her. George Schultz’s grandson, Tyler worked for Theranos for a period of time that ended with estrangement from his family and almost a half a million dollars in legal fees.

As far as employees went, she hired the best but nobody lasted. Problems brought to her attention about the product not working were met with the proverbial axe. Others had a life outside of work and that was clearly contrary to the company’s unwritten policy. They quit.

Can you imagine hiding your operations from CMS auditors?

When an employee on leave committed suicide, Theranos barely recognized the employee’s absence. When her idol, Steve Jobs, died, an Apple flag was flown at half mast outside of Theranos.

Anyone who has ever worked for a fraudulent agency will recognize Theranos. I am sure that every one of her former employees is embarrassed for having believed in her ‘vision’. All of them can see the lies in hindsight and are kicking themselves for not asking the hard questions earlier. There should be an address to send sympathy cards to former Theranos employees.

If you haven’t ever had close contact with a truly fraudulent employer, read Carreyrou’s book and maybe you never will. But don’t count on it.

What are you doing for others?


“Life’s most persistent and urgent question is, “What are you doing for others?'”

Today is the celebration of Martin Luther King Jr.’s birthday. Some of us will go to work as usual and others will enjoy a three day weekend and the majority of us will remember Martin Luther King, Jr. as someone who shaped our nation and inspired us to be better people. I know that he was not perfect but that’s okay. What he stood for and taught was perfect. According to the internet, even Mother Teresa and Gandhi had flaws.

As healthcare workers, we can answer the question posed by King on a daily basis. What are we doing for others? We take care of sick people; elderly people; the most vulnerable individuals in society. We have noble professions. We save lives and help people die peacefully in their home surrounded by family and friends when the time comes. We are compassionate. The support staff that ensure that nurses continue to have the ability to take care of patients are equally as important. We have answers to Dr. King’s question.

But can we do more?

In the spirit of Martin Luther King’s devotion to equality for all, we need to recognize that Healthcare disparities are very real. I am not talking about genetic factors that predispose various races and ethnicities to certain conditions but rather how long it takes someone to receive help and what happens after they are diagnosed.

Black Americans are three times more likely to have a leg amputated related to diabetes than their non-hispanic white counterparts. Areas in the rural south are most vulnerable. I did not need a study to reveal that little secret. The study alluded to the fact that Black Americans are less likely to have their total cholesterol screened and seek treatment later. Another study revealed that they are often checked for diabetic retinopathy later. Still more surprises.

The American Cancer Society reveals that the cancer death rate among African American men is 27% higher compared to non-Hispanic white men. For African American Women, it is 11% higher than non-hispanic white women. This study didn’t allude to any underlying cause but I doubt it has to do with early diagnosis or prompt treatment.

Hispanics have higher rates of cervical, liver, and stomach cancers than non-Hispanic whites.

Non-hispanic whites have a much higher incidence of death from heroin overdoses.

The list goes on as most of you know.

Martin Luther King, Jr. also said, “If I cannot do great things, I can do small things in a great way.”

If you are unable to establish equality in healthcare for everyone, start with your patients. For some, that might mean writing a list of screenings to take to their MD so they can be ordered or results reported to the agency. It might mean arranging transportation for Medicaid patients because getting to the doctor is difficult for rural patients. You might include the family in teaching about exercise to improve circulation to the lower extremities and even encourage them to walk together (because you nailed diabetic foot care). Learn some of the ethnic foods eaten by your patients and help your patients determine a healthy way to prepare them. Be creative. Individualize your care plans.

Statistically, your patients don’t amount to a hill of beans and the changes you effect won’t alter the statistics but your patients are not statistics. Leading a patient and their family to the changes that will forever improve the quality of their lives is a small act of greatness.

Merry Christmas!


wreath (1 of 1)

Here we are again. It’s the Holidays. For some of us, at least. Many of you are still making visits or are on call for the holidays. That’s the life of a nurse or a therapist.

It’s the time of the year for giving and you have mastered that art. When you have no more to give, you find a way when a patient needs you. You listen to the lonely wishing you could do more; not realizing that you are so valuable that you are so valuable that just listening brings comfort and joy. Yet, your children and own family get just as much of you. There will be a time when what you remember most about these times is pure exhaustion and well, happiness.

You bring relief to those in pain using your education, experience and heart. Sometimes, pain is relieved simply by medicating your patient. Other times, you understand that even a hangnail can cause catastrophic pain when your patient’s family members have better things to do than visit over the holidays. You hear the sadness of an elderly patient who has lost his or her spouse and their absence is felt deeply during the holidays. You know that Advil doesn’t relieve ten out of ten pain but the extra visit to evaluate the effectiveness of the medication will.

You intuitively know when a patient is trying to spare you the burden of working on the holiday by minimizing symptoms. They are a little less talkative on the phone or are in bed ‘just resting up for church’ in the afternoon when they are usually up and active. Their color is off and maybe you can’t put your finger on exactly what is wrong but you know it’s there and so you go looking. And just like that a patient avoids a trip to the hospital for an exacerbation of congestive heart failure.

Maybe because there are fewer jobs and more home health aides available for hire, we overlook the value of those aides who have made a career of taking care of the personal needs of our patients. Obviously they bring comfort and ease loneliness, as nurses and therapists do, but they also preserve the dignity of our elderly patients. They are ‘presentable’ when family comes to visit or when they have a physician’s appointment. Patients who were previously known as strong and agile are up in a chair and do not have to have visitors help them get up and ambulate.

During the first part of 2019, there will be changes in the OASIS dataset and payment in the current PPS system. Later in 2019, we’ll be struggling to learn a new payment system. These are critically important to our future but never forget that it is you bringing value to home health and hospice.

And to you I wish a Joyous Christmas and the best year ever in 2019.

Documentation Bloopers


I have an old file of documentation that I have saved especially for you.  These examples are many years old and I have taken great care not to disclose the agency or individuals responsible for this documentation.  Note that these are not my regular clients and I was hired to read the charts after the agency was called upon to submit charts for a ZPIC.  Also, the agencies from which this documentation originated are no longer with us and many of the nurses no longer have licenses.  They were not victims of an overarching regulatory body.  They were victims of themselves.

You may have questions about the clinicians who wrote these notes as I do.  More importantly, where were the checks and balances that ensured that the care was delivered to the patients was sound and documented appropriately?  I could comment and question indefinitely, but you’ll probably see the same thing.

1.       SN instruction given on measures to control hypertension check your blood sugar at least once a day and exercise to lower your blood sugar unless you are sick or have a blood sugar over 240 mg to prevent further complications.

The instruction to control hypertension may include checking blood sugars if the patient has diabetes.  The patient did not.  Exercising once a day may be out of range for most home health patients.

2.       SN assessed all body systems. VSS.  Pt c/o weakness, states I hurt all over.  No meds taken for pain.  SN instructed on factors that increase risk for HTN:  high na+ intake, high cholesterol intake, obesity & sedentary life-style.  Pt verbalized understanding.

This nurse at least tried to follow the care plan.  Could this be the result of a manager demanding that nurses follow care plans?

3.       Instructed if you have any problems with this med go back to ER because we don’t have an order from Dr.

Really?  I wonder if the Doctor had a phone number the nurse could use.

4.       Vitamin A and D ointment topical 1 PO for 7 days.

Sadly, this was repeated over 7 episodes.  Sometimes, it is easy to determine who is reconciling meds on a per visit or per episode basis.

5.       Pt awake and alert but forgetful sitting up in recliner with legs hanging.  Edema noted to BLE.  Slow ambulation assessed.  SN instructed pt to be aware of possible complications of osteoarthritis; Gastrointestinal bleed and stress ulcers.

At first I thought that one little word was missing as in ‘…. be aware of possible complications of osteoarthritis meds….’  A closer look at the chart showed no NSAIDs or arthritis meds.  Still, maybe she took ibuprofen by the boatload and the nurse didn’t deem it important to add over-the-counter meds.

6.       SN assessed all body systems.  VSS.  Denies any discomforts at this time.  SN instructed in possible complications of HTN:  kidney failure, stroke & heart disease.

This patient was on dialysis and had coronary bypass surgery but apparently the nurse was directed to teach only from agency approved teaching guides.  Note that there was no action for the patient to take.  The nurse went into the home and told the patient all the ways he could die and then left.

7.       SN assessed all body systems.  VSS.  SN instructed patient if any problems occur to call 911 or go to ER. Patient verbalized understanding.

Why even bother to send a nurse between ER visits?

8.      Pt is very anxious.  His hands shake – stated he has got to see paleontologist[i] next week.  Client exhibits severe knowledge deficit regarding his disease process and TX regimen.  He is very forgetful and depends heavily on caregiver to assist with his care.  He is highly potential for acute complications of his disease process.  SN to monitor closely and intervene as needed.

Besides the amusement factor of a patient visiting a paleontologist, this was found on four care plan summaries in a row.  With spell check and predictive text, etc., errors happen.  They are corrected when in an agency with checks and balances.

These agencies have other things in common.  Most are making less money than if they hired a couple of extra nurses and employed managers who did not overload their nurses.  Their billing was perpetually late and mistakes in billing were not addressed.   There was a culture of blame instead of support and compliance.  They are owned by people blinded by greed.

I like making money.  I’m sure that you do, too.  We are so lucky to earn our living in an industry that allows elderly patients to remain in their homes and our take-home pay is so much more than a check.  Meanwhile, remember that the real reason for documenting is so that the nurses, therapists and physicians who take care of the patient after you do have access to a true and complete account of the care the patient has received.

Oh, and a Lamborghini has never made anyone’s life better unless they were an Italian race car driver.
[i] I hope nobody was insulted because I linked to the definition of ‘paleontologist’ but I had to look it up the first time I saw it just to make sure I wasn’t slipped LSD.  The definition did not reassure me.  At all.

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.

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