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Posts from the ‘Home Health Physical Therapy’ Category

Making a Statement

Read Haydel Consulting's take on what constitutes useful teaching in the home care and hospice environment.

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Have You Seen Me Lately?

If you ask a home health nurse why he or she needs to examine the feet of all diabetic patients, the answer is usually, ‘Because OASIS C investigates our processes’. That much is true. But there is so much more to the story.

  • Each year, 1% to 4% of diabetic patients will develop a foot ulcer
  • In the course of a lifetime, 25% percent of diabetic patients will develop a diabetic foot ulcer
  • 15% of patients with a diabetic foot ulcer will develop osteomylitis
  • Diabetic foot ulcers hurt and can vastly affect the quality of life of patients
  • The cost of treating a diabetic foot ulcer averages over $45,000.00.

All of this information and more can be found here at the Ostomy Wound Management website.

One of my clients intent on ensuring that every diabetic had their feet checked on every visit created this colorful poster for the office. Shannon Barrillieaux generously shares her poster with us here. To download it for your agency’s use, please see link on the right hand sidebar under ‘essential links’.

Checklist Manifesto for Nurses

Checklist Manifesto

I took the time out to read the highly rated book, Checklist Manifesto by Atul Gawande. No murder, no mystery, just the chronicle of how a pre-surgical checklist was developed and the research that went into it. And yet, I loved it.

Now, nurses are the kings and queens of checklists. Everything we do, practically, can be described as a checklist. Visit notes with prompts for complete head to toe assessments, OASIS assessments, and transfer/discharge documents are all checklists for the most part. We have no shortage of checklists. And it takes a lot for me to suggest one more piece of paper for nurses to include in their daily lives. But that is exactly what I am suggesting.

The Checklist Manifesto explores how a pre-surgical checklist was developed and implemented in multiple countries across the globe. The results were universal. Surgical outcomes improved. Much attention is given to pre-flight checklists for pilots with the result of decreasing plane crashes. Gawande’s supposition is that the more complex our daily tasks become, the harder it is for us to remember all the steps necessary.

The difference as I see it between pre-flight checklists and pre-surgical checklists is that surgeons and pilots pause before cutting or flying and ensure that the necessary steps have been taken to improve the chances of a good outcome. Additionally, because the checklist usually includes multiple parties working together, coordination of efforts is greatly enhanced.

As nurses, we pull out our checklists once we arrive at a patient’s home for a visit. It is when we are isolated without peers that we realize we forgot a teaching guide. Or we have driven 20 miles in bad weather only to find out that the patient was at the MD office. Where is our Pre-Visit checklist?

I have to wonder if a short checklist for home health and hospice nurses might actually improve our outcomes and reduce our utilization. In the coming years, health care reform is going to demand that we use our time with the patient as efficiently as possible.

Of course, each nurse and each agency has its variables. I don’t know if it would be possible to develop a universal checklist for all hospice and home health nurses. But, within your agency, I bet it is worth a try to come up with a short pre-visit checklist. A good start might be:

  1. Patient called prior to visit to confirm.
    1. New drugs in home?
    2. Any concerns that need to be addressed before visit?
    3. If not able to confirm, why?
  2. If another nurse made the visit prior to this visit, has report been given?
  3. Has the current 485 and all orders been reviewed prior to visit?
  4. Are all teaching materials printed and available for patient?
  5. Is there any lab or supervisory visits due?

None of the above items are missed with great frequency by most nurses. However, when reviewing clinical records, it is precisely one of these missed steps that can cause errors, duplicate teaching, missed supervisory visits, etc. In fact, it is precisely BECAUSE these errors are infrequent on an individual basis that they occur.

Nine times out of ten when I discover a trend in clinical records, education is suggested as the remedy. Like surgical teams that do not need to be taught to verify patient identity, some nursing mistakes are not the result of lack of education. Rather the complexity of our tasks is daunting and occasional oversights result in lost revenue, poor care coordination and diminished outcomes.

If you have a quiet weekend ahead of you, please read the Checklist Manifesto by Atul Gawande and let me know what you think. Or if you have already read it, please share your thoughts below in the comments section or email me.

The Psychology of Health Care Spending

I had the privilege of listening to the best and brightest Lawyers and other healthcare experts in Louisiana talk today about Healthcare Reform and what it might mean to our industry. Alas, there are still many unknowns. While the law specifically requires certain things of providers, it offers very little guidance on how to meet those requirements. It will be a long wait, I suspect, until further guidance is available.

One of the guest speakers was Congressman Bill Cassidy from Louisiana. He spoke of the ‘psychology of health care spending’. As I understood him, he supposes that when patients are made aware of how their healthcare dollars are being spent and are encouraged to participate in their care, we will see greater efficiency in the delivery of healthcare. Of course, as a politician, he was much more skilled in delivering his message than I am at delivering it for him.

But it made me think. First of all, in home health, do you really think that if patients were aware that an average home health aide visit to assist with a bath was costing about $60.00, would patients really ‘need’ them? Are patients aware that the average cost of a skilled nursing visit is just over $100.00 and therapy visits are closer to $150.00? In hospice, payment is made for every day that a patient is on service regardless of whether or not any services are rendered on that day. Do patients know that we are being paid even on days when we aren’t scheduled to visit?

Heaven forbid we should burden a patient with financial information when we don’t even burden ourselves with it half the time.

Do we, as nurses, ever think about what our services are costing our payor sources? Frankly, I think we are worth every penny – most of the time. What about those visits we do when we just casually stop by and teach on the first medicine we see? When we spend ten minutes in a patient’s home to give an insulin injection for a BID patient, are we really providing a service worth $100.00?

One way to calculate our worth is to determine how many hospitalizations we have prevented. And yet, even today, I run across nurses who do not know what their agency hospitalization rate is. When I show them their hospitalization rate, they explain that their patients are old and have chronic diseases and are largely illiterate and poor. Hellooo? Who doesn’t have a patient mix that looks like that? None of my clients.

For now, though, as we wait for the inevitable changes to come, we should be focusing on providing value to our payor sources. That means giving our patients care that results in better outcomes and taking the time required to prepare for visits, follow an organized plan of care and keeping our patient at home. That is what home health and hospice nurses do. We care for sick people in their homes.

There’s an App for That

If you are like me, you can’t wait to have the latest gadget. In between playing Scrabble and watching movies on Netflix on my iPad, I have actually found some useful apps related to taking care of patients in their home.

My favorite by far is the WebMD app which is available for both iPad and iPhone. If you are fortunate to have a 3G iPad you can use it in the home for teaching. It has an extensive searchable list of both medications and diseases complete with patient level teaching guides. The same information is available on a PC so information can be printed. I keep thinking how wonderful it would be to have this tool available in the house for those visits when the patient has new medications or a new diagnosis.

The WebMD app also has a searchable list of health care providers using the GPS location of the machine to find results closest to the user. This means that when the patient tells you that their drug store is on Main Street and there are five locations of the popular chain on Main Street, you can narrow it down and call prescriptions into the right place.

Whether you buy your own iPad or can talk your employer into buying one for you, it will definitely make your life easier. Add Netflix and Scrabble and together with your email and music, it is well worth the investment.

I would be interested to hear about other useful apps that can be adapted for use in the home setting for hospice and home health. Geeks like me want to know.

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