May 29
Do you dare? Here is a basic OASIS competency test. It could be that you know more than you think you do or it could be that you might want to spend some quality time with chapter 3. You never know until you try. Click the OASIS icon below to take the test.
Apr 15
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.
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.
Mar 14
No time to blog today. Luckily the OIG has written more than enough.
One in five claims?
Wow.
Dec 4
I received a request posted as a comment on a post written a while back called, ‘Documentation, Again!’ It reads as follows:
I wish you would follow up on this blog as it is connected to the number of visits that nurses are required to do on a daily basis. The “p” word – productivity is the game, as nurses will work off the clock to try not sink in case management and oasis issues. Somewhere in the world a daily productivity of 5.3 patients came around. However with the growth of paperwork and regulations, many nurses who are fighting to be there for their families in the evenings, work on paperwork out of fear. Home Health turnover is high because of this continued lie. You can’t tell nurses that they can completely finish 2 IAs and a visit, fully coding and doing 485 and 486 within 8 hours every time. I had a director who said that to do an IA you should stay in the home about 30 to 45 minutes then finish the paperwork later. Hum, check meds and do an assessment and ask oasis questions and go over plan of care in 45 minutes. How do we turn this lie around, without going to Labor Boards, etc. I believe that sometimes doing less turns out to be more money in the bank, if you focus on getting quality and consistency first, and building from there.
I am nothing if not accommodating, so please allow me to address this writers concerns directly.
Most people think that hell is spelled, H-E-L-L. It is not. Hell is spelled, Z-P-I-C. However, if you are lucky enough to avoid a ZPIC, rest assured in the knowledge that more audits are coming our way. The description sounds a lot like FMR pre-payment audits. Don’t forget about the new Medicaid RAC’s. Any way you look at it, you are likely to be scrutinized in the coming year or so by one or more payor sources who want their money back.
Two admits and a regular visit can be done but not every day. I couldn’t do it. I am not that good and have no desire to be.
As far as charting after you leave the home, that’s not really such a good idea. I think pretty much every nurse has been in McDonald’s or Starbucks charting when they realize they did not assess something. Maybe they started but then the office called to see if they could do another admit and they got distracted. A forgotten TUG score or temp are not really numbers you can just guestimate. Well, you can but documenting your guesses is really crossing the line.
The flip side of not being a slave to an arbitrary number is that productivity often drops when nurses are paid salary. It makes perfect sense on paper to have nurses on salary and ask them to maintain average and reasonable productivity standards but it just NEVER has worked.
I was in a client’s office about two and a half years ago reviewing clinical records when the Administrator, new to home health, asked me to look at productivity. She wasn’t sure but she thought that maybe the RN’s should be able to do more than one or two visits a day. I went about my business because obviously this home health newbie had her numbers confused. Before I left, I asked to look at logged visits. My next thought was that the person doing the logging was incredibly inept at clicking the mouse. Productivity was so absurdly low that I didn’t believe it until I started asking the nurses.
Long story short, she went to pay per visit but didn’t want to cut their pay so she paid them more per visit than I have ever seen any nurse get paid per visit. Sounds like a nut, doesn’t she?
If you think that, you would be wrongo. Her agency, rural, had a greater margin than almost all of my other clients. Her nurses suit up and show up and there is virtually no turn around unless someone is asked to leave. Case conferences are attended. Orders are written. Follow up is a way of life at that agency. Documentation is so good it bores me to tears and they are my only client who received a deficiency free survey this year. If they are chosen for any other audit, I will not lose a minute’s sleep over it.
So my first thought is whether or not the 5.3’ers are salaried or pay per visit. If they are paid per visit, are they making enough so that they can take care of their patients during working hours and be home with their families at a reasonable hour most nights?
I wonder how much those people who push for admissions to be submitted to the office within 8 hours are really losing. Do they know what is in the clinical records? Do they realize that unless nurses are blatantly committing fraud, the aggregate of errors is just about always in favor of Medicare? Those agencies who are brag about 3 and 4 days from admit to RAP are flirting with regulatory and fiancial disaster. Speed and accuracy rarely go hand in hand. The only time a nurse should not take a minute to reflect on her decision is when a patient isn’t breathing and they are turning blue. Even then……….. you got four minutes to consider the most likely cause.
But you asked me specific questions. First of all, I do not know where the 5.3 number comes from. I do remember CMS publishing something like that many, many years ago but it wouldn’t be accurate now. The next question is how to turn the lie around without a bunch of commotion, etc. I can help you there.
When you bring these numbers to the administrator, present them in a way that is impersonal and spread throughout the entire body of nurses. A lot of people want to know who did that, etc. with the goal being to fire the offender. When it is a little bit of everyone, it is more likely a systems or process problem. Explain why each area of compliance poses a threat to the agency.
Weights, lab and MD notification of out of range parameters are all deficiencies. Weights are tied to Congestive Heart Failure and that is the only diagnosis that has been shown to have an influence on home health hospitalizations. I hold Coumadin in the same esteem as I do Oxycontin bought off the street. It is dangerous and a malpractice lawyer’s dream. If the agency is not performing in these areas they are at risk for so many things, it would require the whole internet to put together a complete list.
Payment per episode should be close to $2,200.00 if you have a modest amount of therapy. It should be higher if a high percentage of your patients have therapy. If it is lower, one of two things is affecting it. The first is that the majority of your patients are old. I guess technically they are all mostly old but I am referring to length of time on service with the agency. The second reason may be because the nurses are underscoring in the OASIS dataset and time and education is required to do a complete and accurate assessment.
Now, if your administrator says that they are making a whole lot more than the average or if they say they will go ahead and write the supervisory visits or if they mistakenly believe that they are too large or too small to ever be of a concern to the feds, you need to take a hike. It is Christmas. Spend some time with your family. Do some baking. Start the New Year out in a new job. Can’t afford it? You can afford it more than you can afford to stay at an agency that cares more about arbitrary numbers than patient care. Trust me. I deal with this sort of stuff for a living.
Or have your administrator call me for an unbiased agency assessment by myself or a coworker. As a consultant, I have the freedom to walk away and not have to worry about a job.
Oct 10
I received an email from somebody last week who made the first valid points about The Alliance and associated groups that I have read. Respectfully I do not agree with most of his points, but it did give me pause to consider some of my positions. I remain firm on my position that the exclusivity of these groups and the ulterior motive of some members are reprehensible and contemptible.
That was my disclaimer. Let me share with you one or two of his opinions that hit home.
First of all, CMS is not going to listen to any providers from any sector of the industry ‘whine’ about payment. That much is certain whether you are the Alliance or Joe Bleaux on the street. Fair, according to CMS is determined by the numbers.
I took the time to read the trustees report to Medicare over the weekend so you wouldn’t face that burden. Say, Thank You, Julianne. Most of the information was fairly useless to us as home health providers. Some of it was so boring that I came close to tears a couple of times. But within the report there were one or two things that are important to us as clinicians.
Here are some numbers from the report. Stay with me. Your only alternative is to read it yourself.
Medicare Expenditures for 2010 in Billions
|
|
Part A | Part B | Part D | Total |
| Benefits | 244.5 | 209.7 | 61.7 | 515.8 |
|
By Provider Type |
||||
| Hospital | 136 | 31.9l | — | 168 |
| Skilled nursing facility | 26.9 | — | — | 26.9 |
| Home health care | 7.0 | 12.1 | — | 19.1 |
| Physician fee schedule services | — | 64.5 | — | 64.5 |
| Private health plans (Part C) | 60.7 | 55.2 | — | 115.9 |
| Prescription drugs | — | — | 61.7 | 61.7 |
| Other | 13.8 | 46.1 | — | 59.9 |
The report also said:
It is possible that healthcare providers could improve their productivity, reduce wasteful expenditures, and take other steps to keep their cost growth within the bounds imposed by the Medicare price limitations. For such efforts to be successful in the long range, however, providers would have to generate and sustain unprecedented levels of productivity gains—a very challenging and uncertain prospect.
The last sentence is worthy of repeating. “For such efforts to be successful in the long range, however, providers would have to generate and sustain unprecedented levels of productivity gains – a very challenging and uncertain prospect.”
For the home health care industry, I think it is challenge we will meet.
The next argument posed by the anonymous emailer is that the researchers and brain power in these groups was very high level. I will begrudgingly concede that there is room for this kind of academic and intellectual examination of our industry. But, I am a nurse and I know nurses and we are just as smart, as a whole, as any other group on the planet. Plus we have an edge. Nurses answer to a higher authority than any shareholders, state licensing board, policy maker organization, or even Congress. We answer to the patient first, and then to each other.
So, down to business and I do mean business. We sell health care for a living. In particular, we sell nursing care and to a lesser degree, ancillary therapies. I have used the analogy that home health agencies are like brothels in the past to illustrate that all the payor sources care about is the end product. I was advised that some people may find my analogy offensive. I can’t imagine why the sex industry workers would be offended but just to show my sensitive side, I will not expound on my analogy. The point I was trying to make is that our end product is our clinical care.
In other words, CMS and Medicare HMO groups do not care who has the best accountant or even the most paid lobbyists. They judge us by how well we perform as determined by our cost vs benefit ratio to the overall Medicare budget.
Looking at the budget numbers, the first thing you see is that the bulk of the budget goes towards hospitalizations. Over 168 billion dollars last year was paid to hospitals from Medicare alone and I assume approximately equal percentage was paid by the Managed Care Plans in Part C. If we are competent and keep hospital rates down, we will survive. If we are excellent and reduce overall costs to the Medicare trust, we will be golden. They will turn to us for answers and be eager to give us the budget to care for patients.
Next number to look at is Physician costs. Every time we provide appropriate contact to a physician for a patient already on service we reduce the total payment to physicians. Obviously, physicians are our colleagues and we are not out to eat into their income. But, I think even the doctors appreciate a nurse who recognizes the need for intervention and arranges for it with his assistance as opposed to interrupting his day with an unplanned patient visit. If you keep their patient out of the hospital, you have proven your worth to them more than any expensive dinner or cute little sticky notes.
Look at the part D drug expenses. We like drugs. Patients like drugs. Drugs are good things. Nurses, in particular, are fond of drugs. How many of you have ever wished for a Xanax or Prozac salt lick in the office. By making a concerted effort to truly examine our patients’ medications and identify duplicate and ineffective therapy, we both improve care and reduce the risks of hospitalizations. When we identify medications that are ‘left overs’ from an illness the patient no longer has, we save money. We don’t do that. I know it says that we do in the OASIS, but as an industry, there is vast amount of room for improvement. We do not need policies or pathways to check medications. We just need to remember to do it and address all inconsistencies.
Nursing home care is expensive. The part of nursing home care that Medicare pays for is ‘skilled’ needs much like the skills we can and do provide in the home. Ask yourself; is it better for the patient to be in the home or in a nursing home? If you can provide those same skills at a lower level of expense than a skilled nursing facility or rehab hospital, you can save the Medicare system money. Better than saving money is that you may be able to keep the patient in his or her home where life is much friendlier.
So, there is your challenge. You in?
