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Posts from the ‘medications’ Category

Guess What Happened!


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.

Work with Me, Folks!!!

deniedFor the past several months, I have been arguing with pretty much every payor source for home health there is trying to get clients paid.  After working with dozens of clients in multiple states, I am fairly confident in stating that some of you simply do not want to be paid.  If you did, you would give me and other consultants and lawyers something with which to work.  Just to be clear, I cannot work with:

  1. ‘Take meds exactly as ordered’.  (variant:  take meds at the same time each day.)   It does not require the skills of a licensed nurse to tell the patient to take meds exactly as ordered. The general rule of thumb is that if you can learn it on Oprah, it probably isn’t skilled.
  2. Duplicate medications.  Alone, duplicate medications place a patient at high risk for adverse events.  Combined with number 1, it shows anyone who cares to read that the patient should not take meds exactly as ordered.
  3. I read this in a clinical record:  I noticed the patient had enough money to buy cigarettes, but claims she can’t afford her medical supplies.  Work with me people!  You don’t get paid for your personal judgment.  The patient was at 77 percent of the poverty level. Refer to evidence based practice when you feel tempted to commit to legal documentation your personal disapproval.
  4. Prior to charting edema on a lower extremity, please ensure that the extremity is present.  I promise that if you have check boxes for right and left pedal edema and you pull all your patients who have less than two lower extremities, you will find phantom edema.  The same applies to diabetic foot teaching, pedal pulses, etc.
  5. It is not enough for a physician to document that a patient has a diagnosis.  You must also know what the diagnosis is and how to provide nursing care for the condition.  I just read an admit for a patient who was referred with Pickwickian Syndrome which was named for a very round faced portly character in the first novel written by Charles Dickens.  Because Mr. Pickwick was known largely for his girth, the condition has been renamed  ‘Obesity Hypoventilation Syndrome.  There were no orders for diets or attention to respiratory status.  I  don’t think the nurse looked up Pickwickian, do you?
  6. Diabetes Type I and II are not interchangeable.  Work with me, folks.  These older names for diabetes confused a lot of people so they have changed to simply Type I and Type II.  Type I diabetes accounts for less than 5 percent of diabetes in the elderly.  What on earth are y’all gonna do when when they recognize diabetes 1.5 as a separate diagnosis? (For now, just code as 250.00.)
  7. MD Awareness Month.  It must be MD Awareness Month because every day I read about an MD who is aware.  It goes something like this.  ‘Pt’s blood pressure is 190/100.  Patient has not taken medications.  MD aware.’  I believe that is a convoluted way of stating that you didn’t call the physician as warranted by the MD stated parameters.
  8. Someone named Pt/Cg is wandering through the homes of all home health care patients in the country.  Typically this occurs in computerized documentation that has not been edited correctly.  It makes less than no sense that you taught pt/cg in an Assisted Living Facility that Alzheimer’s is a progressive neurological disease which results in mental deterioration and eventually death.  Which caregiver did  you teach?
  9. Notifying the caregiver is a bad idea.  Imagine if you had an INR come back high and you notified the caregiver to hold the Coumadin and documented that you did so.  What if the patient had multiple caregivers and none of them held the coumadin?  What if the patient had a bleed into their brain and none of the caregivers remember the conversation and you didn’t write down a name.  Think that’s over the top?  It is.  But it happened to a client a year or so ago.  Caregivers have names for a reason.  Use them.
  10. Repetitive teaching.  The second most common reason for denial is that the documentation does not meet the standards for reasonable and necessary care.  Teaching is the most frequently provided skill in home health.  You with me?   So, in order to be paid for your services, you must teach original material or have a reason for re-teaching.  It is unreasonable to teach diabetic diet, foot care, skin care and insulin injections in a single visit.  Don’t chart that you did.  Use teaching guides.  Your patient is elderly, in pain, has poor vision, intermittent confusion, and takes drugs that impair mentation.  That might be something to keep in mind. Take your time.  Teach at the pace the patient learns and document what you did.

So, maybe I am a little frustrated this weekend but I love my job and I love home health and I take it a little personally when payor sources deny claim after claim sending the message to my clients and colleagues that what we do is not worth getting paid.

Cardiac Med Competency

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Cardiac Meds

Drugs and Theft


I received an email  fromMedscape about continuing education on Opiates today.   I figured it would be an easy way for me to add to my licensing requirements because I happen to love opiates.  Morphine is my favorite.  Understand that I have only had it once after surgery but as a nurse, I can’t say enough good things about Morphine and it’s friends.

Did I mention that my clinical experience is mostly in the CCU and that I have a lot of hospice clients?

That last piece of information is very important.  Morphine is a great drug for relieving pain and in the CCU, it has the added benefit of dilating constricted arteries which may be causing the pain thereby eliminating the source of pain.

In the home setting, opiates are a different story.  Every day I read clinical documentation and I see where nurses teach patients how to take pain medications appropriately and how to manage side effects.  I read nurses teaching alternative pain relief measures.  Every once in a while I see a chart where I am suspicious of the amount of meds prescribed to a patient .  But I never see anything written about Medication storage and disposal in home health.  In hospice, you see a great deal of information about drug disposal after the patient has died.

I suspect that is because we have all assessed our patients are comfortable with the orders for pain meds that the MD has written.  If our 90 year old patient is in pain we do not consider the possibility of addiction when treating her pain.  What we don’t always think about is the other people who come into the house.

Here are some alarming statistics:


In this slide, shamelessly stolen off the Medscape Continuing Education activity, you see that buying drugs from a dealer is far less frequent that getting them from a friend or taking them from a relative.  The internet pharmacies that were supposed to ruin America do not make a significant contribution.

This next slide (also stolen) should make us proud.  It shows that America’s youth are more generous than Canadian youth.


What all this means is that we need to start teaching the risks of drug misappropriation to our patients.  Even though they may know their own family,there are many people who have figured out that scoring drugs from an elderly confused patient is cheaper and less risky than buying them from a dealer.   We should teach patents or assist them in putting narcotic pain relief out of sight or under lock and key.  We should teach them proper disposal of medications.  And if there is any suspicion of misappropriation, pills should be counted just as they are in the hospital or other setting.

I really encourage you to take advantage of this free continuing education from Medscape and use it in your practice.  It doesn’t take long and it may open your eyes to a threat you never considered before and allow you take action before someone gets hurt.

Plus if you take thefree continuing education activity, Medscape will be less likely to write me nasty letters for stealing their stuff.  I prefer to download the transcript but there is a video discussion for those of you who do not like to read.

By the way, don’t start talking about ‘Julianne, you know, the nurse who loves Morphine’.  It just doesn’t sound right.

A Slap in the Face

So last week I was reviewing clinical records at the office of one of my favorite clients.  A patient had been admitted six months after having half of her foot removed.  She had not walked since the surgery and was confined to the bed and the chair.

The first thing I noticed was that the description of the surgical wound sounded as though it were partially granulated instead of fully granulated.  Six months is a long time but remember, amputations are not cosmetic surgery.  It would not be unheard of to have a wound slow to heal in someone with circulation impaired to the extent that part of a foot needed to be removed.

I also questioned the diagnosis sequence and a couple of the OASIS questions in the functional domain.

Med orders on the 485 indicated that the patient was on both Dilaudid an Lortab but the chart only mentioned Lortab as being used for pain.  My most humble opinion is that if pain is being managed with Lortab, the Dilaudid should come off the orders – especially after the first episode.  The reason I feel this way is because if the patient had a sudden need for stronger pain relief, she may have other needs than Dilaudid that should be addressed immediately.

She had both therapy and nursing ordered.  The nurse was quick to realize that the new orthopedic ‘boot’ designed to help her walk was causing the surgical wound to become red and irritated.  Both the nurse and the therapist addressed this with the MD and the people who made the boot.  I certainly cannot complain about that.  But, after the boot was refitted properly, the nurse stayed in the home weekly even though therapists should be able to assess wounds.

In summary, I saw was that OASIS scoring left the agency with less payment than they were ethically entitled to for a very expensive patient and services being provided that may not have been required.  And of course, there was the regulatory issue with duplicate pain meds.

While I was busy finding fault left and right, the most important thing almost escaped my attention.

After two episodes the patient who had part of their foot removed and had not walked in six months prior to admission was ambulating with a walker.  The last nursing note state that the patient was in the kitchen upon arrival making coffee and using her assist device.

I am still not happy with the chart.  My slap in the face comes from the fact that sometimes we forget that documentation is second to our real mission of providing care in the home.  It is a very close second but failure to acknowledge what these incredible nurses and therapists did for the patient is the kind of attitude that deserves a slap in the face.  If those of us who review charts on a regular basis cannot read between the lines and respect the care given to patients, we have no right to expect respect from field clinicians when we tell them all the things they did wrong.

Having said that, I have seen like a billion ADR’s and ZPIC denial letters but I have never seen one like the following.  Please forward to me if you have.

Dear Administrator:

After careful review, our Medical Review department has determined that the cases mix weight determined by your OASIS data is in error.  Specifically, a surgical wound and the functional domain were underscored resulting in a lower payment for this patient.  In light of these egregious errors, Palmetto GBA (ZONE contractor or MAC of your choice) is adjusting your claim to reflect the correct diagnosis, surgical wound and functional status of your patient.  This will affect the overall denial rate on your current edit.

As a provider, you have certain rights to appeal.  Please see attachments on how to appeal a Medicare decision regarding payment.


(Insert the name of your MAC or Zone Contractor)

PS  please advise your nurse to take Dilaudid off the current med list and ask the patient to place it in a Ziplock bag with a large note that tells the patient to please call the nurse immediately should it be required in the future.

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