Skip to content

Posts from the ‘medications’ Category

How to Reduce Hospitalizations

First of coumadinall, I am getting some really good information from the Medicare 101 quiz posted Sunday evening.  When the responses stop coming in, I will share some of the more interesting results with you.  It will certainly give us some useful information to use when writing posts in the future.

As I suspected, Coumadin should be a schedule II medication controlled to the same degree as Oxycontin and other medications that shouldn’t be distributed freely due to the risk of untoward side effects up to and including death.  Now, I have proof.  Medscape has a new, very short CE activity that offers evidence to support my position.

After reading the CE article, I am sure you will agree with me that the best way to prevent unavoidable hospitalizations is to discontinue Coumadin on all of your patients.  Seriously, if I was an ambulance chasing lawyer, I wouldn’t spend money on TV commercials for my law practice. I would advertise Coumadin.  If your stodgy MD’s don’t agree with my assessment, at least consider upgrading your communication processes related to Coumadin.

(By the way, in case you think Pradaxa is the answer, you may want to rethink your position.  Four days ago, the FDA issued this warning about Pradaxa.  I only skimmed through it but I believe it said something about post marketing reports of bleeding putting the patient at risk for hospitalization or even death.   That is never good and almost always messy.)

So I guess that leaves us with good old fashioned nursing care as a solution.  Consider using SBAR-C communication when communicating with others about Coumadin.

    • S – Situation
    • B – Background
    • A – Assessment
    • R – Recommendation
    • C- Communication


Situation:  I just drew lab on Ms Smith as ordered a week past her last dosage change of Coumadin.  She is currently on 7.5 mg daily and her INR is now 4.2.

Background:  She had a mechanical valve replacement two years ago and did fine on her Coumadin until recently.  Her INR’s decreased to sub-therapeutic in recent months.  Her two most recent INR’s and corresponding dosage changes are: (give example).

Assessment:  She has no signs of external or internal bleeding.  (give vital signs)

Recommendation:  Do you want me to hold Coumadin for a couple of days and then restart?  If so, what do you want her dosage to be?

Communication:  Gave above orders to JUDY, patient’s daughter who stated she was removing the Coumadin from the patient’s med planner box now and putting the bottle of Medicine on top of the refrigerator so it wouldn’t be mixed up with normal meds.

All of these steps are important but detailed communication of orders is the most frequently missed step.  It is also the step that could get you into serious trouble if the patient ends up in the hospital with a bleed to the brain.  Documenting that you told the patient’s daughter is all well and good if she only has one.  It is always best to document the name of the person you told and the time and date of the phone call.  Details lend credibility.  (And details are always easier to provide if you document contemporaneously with your work but that is a subject for another post.)

Sometimes, there is nobody reliable to instruct on changes.  In that case, an additional skilled nurse visit should be ordered so the nurse can go to the house and remove the Coumadin herself.  Since we know that unstable Coumadin patients are going to have a lot of unanticipated lab and orders, conservative scheduling with PRN orders for medication updates should accommodate the needs of the patient without breaking your budget.

Or, you can go back to my original advice and discontinue Coumadin on all of your patients but before you do that, let me explore some of the regulatory issues that may arise if you don’t follow physician orders.  I seem to remember reading something about that somewhereSmile.

Spelling Lesson

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.

  1. Get all the information you can about the agency as a whole.  This is not about you or the administrator/DON.  It is about whether or not patient safety is protected at such a fast pace. Information that is relevant:
    1. Hospitalizations as reported on CMS along side your three biggest competitors.
    2. Average HHRG’s or payment if you can get it
    3. Other outcomes are not as useful but run them anyway.  Choose your three biggest competitors and run the reports from
    4. Number of call outs in the past 6 months from HR
    5. Do some research.  This problem wasn’t created overnight and it will not be solved overnight.  Two more weeks will not make a difference.  Once a day, look at 10 charts for one specific thing.  It will be real easy if you use point of care.  Suggestions:
      1. Home Health Aide supervisory visits
      2. Weights recorded and reported as indicated
      3. Physician notification of out of range parameters
      4. Lab drawn timely and reported.  If orders were issued as a result of the lab, are those documented and who was notified of them?  (Check your Coumadin patients.)
      5. Are diabetics taught foot care every episode and is it done per ordered?
      6. Is pain noted on the visit sheet and if so, what was done about it?
      7. I am willing to bet you ten thousand dollars that if you grab 10 485’s and look at all the medications, you will find issues.  Put them in the free Medscape interaction checker online or use iPhone/iPad app.  Look only at the most critical ones listed first.

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.

Follow Up on Documentation Quiz

The documentation quiz was so much fun.  We must do it again soon!  I loved your responses.  I must admit, the bonus question about what would happen to the agency if ever they were ZPIC’d lacked originality most times.  The words ‘denial’ and ‘jail’ came up a lot.  Someone wrote that Medicare would be confused if they saw the documentation.  Another writer wanted to know how long the patient had been extinct if they were seeing a paleontologist.  Let me stop here and tell you that although I have looked and cannot find it written anywhere, it is my strongly held belief that Medicare does not pay claims on dead people.

My favorite was from a nurse who emailed me and wrote, “So, I spend a lot of time trying to teach nurses how to document.  I really don’t enjoy as much success as I would like but it isn’t for lack of trying.  If this sounds familiar, I plagiarized it.”  I love it when someone really understands my frustrations!

The one that almost made me score a 1 on M1610 was this one:

This am your bestest post I have ever seed. I am going to notify the paleontologist of the potential for increased humor if the examples are ingested topically first thing in the morning.

Now I have to go see my doctor for severe laughoutloud developed this morning!


PS…You just can’t make this stuff up…have you thought about a book?

I would like to write a book someday but I love the blog and it will do for now.  Writing is solitary.  Blogging is like spending time with a bunch of nurses a couple of times a week.  I learn more from y’all than you will ever learn from me and I miss spending a lot of time with nurses the way I did at the hospital or the large organization down the street from me.  When I visit agencies, I am always mindful that I am on someone else’s clock so I try to stay focused on my task at hand.  Boring…….

I wanted to follow that post with examples of good documentation but I can’t.  Good documentation includes too much information that should not be published on the internet.  Plus, it occurs over the course of an episode and includes things like lab follow up, med changes in the computer, etc.  No single note is good.  If you don’t believe me, I will send you four perfect notes with the identical language in them for four consecutive weeks.

I had one response that read as follows:

I review charts daily for my organization.
I do believe the documentation you show above could be used for educational purposes, or as a reason for dismissal.
I do not, however, understand the sarcasm. These snippets were written by, supposedly, professional people.
I am embarrassed for them. How can they call themselves nurses? Their documentation portrays them as ignorant, and puts them at risk for lawsuits. Who would be crazy enough to defend them?
I am not sure remediation would prove beneficial to either the agency they work for or the patients they service.
Feeling pretty good about the charts I review now.

I do understand this response.  The sarcasm is a product of my sense of humor; nothing more and nothing less.  As far as who would be crazy enough to defend them, I can give you some names but you would have to remember that while an agency is rather pathetic in its performance it does not mean that everyone associated with the agency is ignorant and pathetic.

I personally have charted that Dr. Kevin DiBenedetto was at the bedside attempting to urinate.  X3.  Unsuccessful.  (The doctor did eventually intubate the patient successfully and a few hours later I was finally able to go to the bathroom.)  According to my documentation, I also gave a complete blood bath that surprisingly, the patient tolerated well.  Another time, Super Nurse here got a patient and walked with him outside the day AFTER he died.

The difference between my erroneous documentation and the stuff I posted is that somebody found these mistakes almost as soon as they were made.  My back was covered.  If I had been asked a year later about a home visit where I walked with a patient outside the day after he died, I wouldn’t have been able to legitimately and ethically correct the date.  If Medicare had discovered it, it might have been viewed as fraud.  I would hate to be questioned in a deposition about how it came to be that my patient tolerated a blood bath well.  (“I told you I was good.  Now do you believe me?”).

These charts I took screen clippings of were spread over the course of a year.  How does that happen?  How can such outrageous documentation be present in the clinical records and everyone is clueless?  I assure you that it is NOT a nursing problem.

The first thing that the respondent above wrote was, “I review charts daily for my organization”.  It is an expense to the organization that employs this nurse that is not directly revenue producing.  It is very difficult to quantify the amount of value she brings to the organization in a spreadsheet.  There is no formula that says if she does ten clinical record reviews, the agency will be ahead X number of dollars. In fact, this nurse may do a lot of work that actually identifies errors that result in lower payment to the agency.  So, it stands to reason that the organization cares about the integrity of its documentation, ethics and is sophisticated enough to recognize the value of risk reduction.  I hope they call me if they get a ZPIC letter.  I like winning.

The organization which employs the nurse is also concerned about the quality of care.   He or she did not leave a name so I don’t know what pronouns are appropriate but the organization employing this nurse has created a culture based upon the quality of care of the patients.  Even the best, most caring non-clinical person cannot set policy about patient care.  You don’t see nurses trying to handle billing and accounts payable and you shouldn’t see CFO’s making clinical decisions.

This nurse also wrote that she wasn’t sure that remediation would be beneficial to the nurses or the patients.  Medicare agreed with her.  They didn’t do anything drastic like take back the provider number.  They did something much more effective.  They stopped payment completely and now the agency is gone.

ZPIC 1 – Agency 0

Oh, by the way, if I didn’t have a sick and twisted sense of humor, I would not be able to do my job.  I would rather work at Taco Bell if I took this stuff too seriously.   But I apologize if I offended you.

Medication Competency


This list of the top 15 drugs prescribed in the United States thus far in 2011.  The good news is that they are all generics meaning they are available at a lower cost.  The bad news is that because they have become so common, we forget that these are major pharmaceuticals that can cause major problems.

If you’ve been paying attention, you will realize that the key to doing well in 2012 is directly related to your ability to keep patients out of the hospital.  In reviewing hospitalizations and  Reason for Transfer OASIS assessments, I would bet the farm that medication errors are a direct or indirect cause of a lot more hospitalizations than are reported.

When I read charts, I also see very vague medication teaching.  In reviewing clinical records it is not unusual to see ‘teaching’ such as:

  • Taught patient to take meds exactly as MD ordered.
  • Call MD for any side effects.
  • Take insulin at the same time each day.
  • This medicine helps to lower your cholesterol

I understand that patients have different learning abilities and that sometimes the best we can do is teach the patient the bare minimum.  But whether we teach a lot or a little about medications, it isn’t working.

The first step in providing really effective teaching about medications is to know your medications.

To see how well you or your staff know your meds, click here to take a basic medication competency test.  Until you are able to answer the questions with complete confidence, keep researching.

Of course, not every can know every medicine but there are tools that can be used.  My favorite for when I work offsite is the Medscape app (available for iPhone, Droid and Blackberry) which has two options for download.  One is a smaller download and the larger download includes the entire database for use offline.  Using the larger download option, nurses are able to look up drugs and interactions on their phone even when the internet isn’t available.  It is amazing the things I find when I use it.  The downside of the app is that it does provide every possible drug interaction in the world.  I try to focus on the most serious interactions and read through the remainders to see if they apply to a particular patient.

By really looking at meds and planning teaching as you write a careplan, you can gather all sorts of appropriate teaching materials for the patient.  Medications are also my favorite hunting ground to see if any diagnoses have been missed.

Let me know what you think about the competency test and how you scored.  If you have any other questions to add, please feel free to email them to me or to post below.  Heaven forbid I made an error in the test.  If that’s the case, please post below.

You In?

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?

%d bloggers like this: