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Oct 24

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Med Competency

Seen something like this before?

Here are the long awaited answers to the Medication Competency test.    For those who asked, I am delighted that you think enough of the test to want to use it in your agency and I grant to you my full permission.

The test was hard but honestly, I chose most of the questions from medication monographs that should be used in teaching meds.  Mona Landry made an excellent that they were available in their CareAnywhere program.  They are also available on every point of care software I have used with clients.  So, let that be a lesson.  Just because nurses have the tools does not mean that they will use them.  For agencies without point of care, you certainly have the internet.  In fact, over 85 percent of homes in the country are wired to the information superhighway so information is available everywhere.  Even on smart phones, drug information is available.

So why aren’t we looking up medications?

In order for me to make an effort to learn something new, I must first be aware that I don’t know something.  But that isn’t enough.  Surprisingly, there is much I do not know about nuclear physics  and stamp collecting.  I am only motivated to learn when something interests me or the information will help me in my daily activities.  I am one of the most fortunate people on earth that what interests me is also part of my work.

Periodically testing competency accomplishes only the first part of the learning process.  I believe that nurses do not regularly research medications because they are unaware that they lack knowledge.  I know I am frequently surprised when I research common medications.

Unlike nurses in the field, I am pretty confident that anything I write down for this blog or anything that goes into a report for a client will be read and analyzed.  In order to ensure that I offer only good information, I look things up regularly.  I read the program integrity manual (ZPIC work), Medicare Beneficiary Manual (chapter 7, I believe is home health these days but it may be 6), the State Operations Manual, the OASIS manual and various state regs all the time.  I keep copies on my iPad for when I visit client offices.

Because my work is reviewed (at times scrutinized), I am made aware almost immediately when I make a mistake.  Field nurses who chart inaccurately about medications may assume that they are correct in their teaching because they have taught this way for years and nobody has said anything about it.

A field nurse may assume that he or she knows what is required to Proton Pump inhibitors.  After all, most patients take at least one.   Do they really need to be on them or are they left over from a prior illness?  Manufacturer’s information states that these meds should be taken for 14 days.  Our patients take them for years.  But because no one has ever died of proton pump inhibitor overdose (to the best of my knowledge), we assume they are safe.

In addition to the safety of the medication, there are costs involved which are burdensome to the patient and to the payor sources.

In doing ZPIC work, I see tons of opportunities for agencies to have provided reasonable and necessary care that were overlooked.  From a ZPIC perspective this costs money.  From a nursing perspective it costs our patients more than they can afford in quality of life and potential side effects.  Although it doesn’t seem like it at times, we are being a ton of money from Medicare to provide reasonable and necessary services to patients.  Reasonable and Necessary means that only a skilled nurse can perform the skill safely.  When it comes to teaching and training, my general rule of thumb is that if the information is available to anyone who watches Oprah, it really doesn’t required the skills of a nurse to teach.

Examples

Good:  Taught patient that Coumadin is given to prevent blood clots but it can also cause excessive bleeding.  In order to take the medication safely, blood tests must be performed periodically so the medication can be adjusted.  Because large amounts of vitamin K affect the medication, you should not increase or decrease the amounts of green leafy vegetables normally eaten as this will affect your lab results.  If you miss a dose of Coumadin, be sure to call the agency.  After missing a dose, the lab results may be low for a few days following the missed dose.

Bad:  Taught patient to take Coumadin exactly as ordered and to keep all follow-up MD appointments.

Email me any questions or comments.  If you have any competency tests you would like to share that are in the public domain (not subject to copyright laws), please send them to me.

Oct 6

4 Comments

Bill Borne, CEO of Amedisys Responds

Today, for the first time, I am going to present to you factually false information on my blog.  I do not know which information is false but I have received a lot of conflicting information from various places.

The delay in posting Bill’s response is a result of the fact that Bill’s initial response did not satisfy me in that I do not understand what he means about rebasing and then staying the cuts in 2014 and how this could possibly be good for the industry.  I fully agree that there is a lot on the financial and political side that I do not understand.  But within that email, Bill writes:

My colleagues, which are not an exclusive group, are working together with the whole industry to help stay the damage by working on positive messaging. These organizations are open to anyone who wants to step up to the plate in the industry and invest their time and money.

This came after the email from Keith Myers who said that the Alliance for Home Health Quality and Innovation are not in the business of lobbying.  I took Bill’s note on ‘positive messaging’ to be a euphemism for lobbying so I contacted him and gave him a chance to clarify his position.  Bill also received Keith Myers response to my original post which stated emphatically that no lobbying or legislative activity occurred.

That resulted in a phone call from Bill last Thursday.  During that conversation, he was adamant that Keith was one hundred percent correct.  He also said that perhaps I was confused.  There are and were multiple organizations out there and perhaps, I found information about the wrong group.  It is a sad fact for me that such a scenario is extremely possible so I found the lobbying reports forwarded them to Bill.  It was not my goal to discredit him personally so I offered him an opportunity to reconcile the lobbying reports with his position.  I did not hear back from him until late Friday afternoon.  See for yourself if he explains the lobbying reports.

September 30, 2011

To the Editor,

Last week, Reuters published an article that quoted me as calling for the government to provide home health providers greater clarity concerning reimbursement rates, in which the reporter noted that Amedisys and other publicly traded home health providers were lobbying Washington to accelerate the rebasing process. This article has generated a lot of attention, and I have received many questions seeking greater clarity concerning my comments. Accordingly, I wanted to take this opportunity to clarify my position regarding these matters.

As you may know, a report by the Moran Company from earlier this month analyzed the potential impact of CMS’ proposed 2012 reimbursement cuts and concluded they would lead to negative Medicare financial margins for 52.3 percent of all home health agencies in the U.S. This report can be found on NAHC.org.

As the Reuters article reported, it is true that several members of the home health industry have formed the Alliance for Home Health Quality and Innovation dedicated to improving the nation’s health care system by supporting research and education to demonstrate the value of home-based care. However, the lobbying efforts referred to in the Reuters article were not, as stated in the article, undertaken by the Alliance, but rather by another group called The Partnership for Quality Home Healthcare which represents more than 1,800 community- and hospital-based, non-profit and propriety home health and hospice agencies nationwide and NAHC to develop innovative reforms to improve the program integrity, quality, and efficiency of home health care for our nation’s seniors.

Amedisys supports both the Alliance and the Partnership, and has also been a long-standing supporter of NAHC, which represents all home health care providers.

We invest our time and energy in these efforts to protect patient access to home-based health care for the more than 3.2 million Americans who rely on us. In doing so, we improve patient lives and the health of the Medicare system by keeping our nation’s chronically ill seniors out of the hospital and other more expensive facility-based settings.

The point I made to the Reuters reporter is that, despite the significant cuts in 2011 and 2012, our industry continues to face additional threats from many different sources, in the form of rate cuts, accelerated rebasing and calls for the implementation of co-pays, leading to great uncertainty about the future. Without a predictable and reliable long-term source of revenue, it is very difficult for any company—large or small—to form or implement a successful business plan or make the long-term investments necessary to support a healthy, sustainable organization.

In speaking with the Reuters reporter, I was speaking on behalf of myself and Amedisys only, not on behalf of the Alliance, the Partnership, NAHC or any of my colleagues. I personally support the effort to press Washington to provide our industry with a comprehensive reimbursement plan that we can be certain will be in effect for the long term. We deserve clarity on just how far the cuts will go. We need clarity so that we can plan ahead for mission critical business decisions such as hiring talent and investing in new clinical programs. If we leave rebasing totally up to CMS, each year through 2017 we will be forced to operate in uncertainty, taking us away from investing in patient care and instead worrying about which shoe will drop next. This uncertainty is simply not tenable—for any of us, or for our patients.

In my opinion, without the type of proactive initiative being spearheaded by the Partnership, we will certainly get an additional reimbursement cut in 2012, and again in 2014 when mandatory rebasing is implemented. The intent of my statement was to have the industry endure only one reimbursement cut, that we would have a say in and that would take place now, and that would be in effect for the long term, so we can operate our businesses with some certainty and confidence about the future.

I invite and encourage all home health care providers to help our industry by being active with any of the organizations formed to help increase awareness around the work we do helping and healing people each day.

We should not be divided. We need to have a joint effort to protect home health care. Our patients are depending on us to come together and protect their access to care.

Sincerely yours,

William F. Borne Chairman & CEO, Amedisys, Inc.

As mentioned previously, there is something factually false on this blog.  I am not in a position to know if Bill, Keith or the Lobbyists in Washington are the ones who have provided factually false information.   Bill and Keith can’t seem to get their stories to correspond on whether or not the Alliance actually engages in in any political activity or lobbies.   Read Keith’s very clear statement about the Alliance here.

If you read Bill’s statement carefully, you will see that he didn’t actually deny that the Alliance lobbied.  He said, “However, the lobbying efforts referred to in the Reuters article were not, as stated in the article, undertaken by the Alliance, but rather by another group called The Partnership for Quality Home Healthcare.”   So if the Alliance didn’t take on lobbying efforts referred to in the Reuters article, what efforts did they undertake?  Here is the lobbying budget for the Alliance of Home Health Quality and Innovation for the past four years.

This is the composition of the Alliance of Home Health Quality and Innovation from their form 990 filed in 2009.

On the Alliance’s 2009 Form 990 signed by , an IRS document required to be filed by all non-profits, the second page states, as attachment 2:  (bold lettering mine)

2009 was a transition year for the Alliance.  The Alliance has reorganized its working groups to address:  research, education of policymakers, internal and external communication, memberships, relationships with other professional organizations, quality and technology and innovation.  It also established working relationships with key policymakers at CMS, MEDPAC and other public and private organizations.  The Alliance has also held educational sessions for federal officials on the value of the home health benefit.

My understanding is that lobbying is an effort to gain political influence.  Truthfully, there is nothing wrong with that.  When a group of passionate people who openly state their purpose and do their best to persuade policy makers to make changes, the results can be amazing.  Going back to that little form 990 again, we see that simply joining a group does not give you an opportunity to facilitate change.

The Alliance shall have two classes of members:  once class of members with voting rights and the other class without voting rights.  Only members with voting rights may designate a representative who shall be eligible to be elected as a Director (it being understood that not all voting members shall be entitled to have a representative to serve as a Director).  The board of Directors may establish different dues categories and member designations in each class and shall otherwise determine all other rights and obligations of the members.

The Alliance also had to list its board members on the IRS form 990 in 2009.  This is taken from the IRS form 990 which exempts this organization from paying taxes.  Keith Myers signed the form.

Bill Borne Chairman and President
Ron Malone Vice Chairman
Val Halamandaris Secretary
Bill Yarmouth Director
MikeBayada Director
Chris McInnis Director
Keith Myers Treasurer
  • Once you get answers to some questions, even more arise.  Those that come to mind immediately are:
  • How can the lobbying reports be reconciled with the statements Bill and Keith made?
  • Is there a meaningful difference between ‘establishing working relationships with key policy makers at CMS, MEDPAC and other public and private organizations’ and lobbying?
  • Bill states the Alliance is open to all.  I have a whole lot of emails from home health agencies all over the country who state they never heard of it until last week.  If it is open to all, how much does it cost to join?  How much does one have to pay for voting rights?  What did the current members pay and is that public information?
  • Does NAHC have voting rights?  If so, on what scale?  If the voting rights of NAHC are proportional to Amedisys and LHC representatives, it stands to reason that the entire industry is not being represented proportionally.  If so, the name of the organization should be changed to, ‘Alliance of Really Big Home Health Companies’ .
  • If any topic arises that NAHC could be outvoted on by the large corporate entities, NAHC doesn’t belong in the Alliance, period.  That’s Julianne’s opinion.  No one else’s.
  • Do the members of NAHC know that their organization is part of a small group of very large players chaired by Bill Borne?
  • How much of NAHC’s membership dues went to pay the dues for being a member of the Alliance?
  • Bill proudly states that the Partnership for Home Heathcare represents more than  “1,800 community- and hospital-based, non-profit and propriety home health and hospice agencies nationwide and NAHC ….”  If you add up the number of agencies owned by Amedisys, LHV, Gentiva, Almost Family,Bayada and the VNA, I wonder how close the total is to 1800?  NAHC has 33,000 members according to their literature.   Which ones did NAHC choose to support?
  • Why is the Alliance for Home Health Quality and Innovation not listed on the NACH website under the affiliated organizations page?
  • Oh, and can somebody tell me who the Partnership for Quality Home Healthcare is?  The  information I know for certain is that they have a very large lobbying budget.  Nowhere on their website is the name of a manager, director, contact person, etc. mentioned.
  • Would the Avalere study emphasizing the benefits of home health have been more credible if the members of the Alliance hadn’t have paid for it?  It is understood in academic worlds that conflicts exist but conflicts of interest do not discredit a study nearly so much as the non-disclosure of said conflict.  By hiding behind the cover of the Alliance, a very expensive study was paid for by the largest home health care companies in the US.  I think that is relevant information.

As interesting as these questions are, nobody owes me an answer.  It is the agencies who compete against the larger publicly traded companies that need answers.  It is the 3,3000 home health agencies who are NAHC members that deserve to know these answers.

I encourage your comments.  However, since this is my domain, I could be held responsible for anything  published here.  I will withhold any comments that are overly insulting to any one individual or that make accusations that I cannot independently verify.  My goal is not to ‘attack’ any one individual or company.  My goal is to alert you to the fact that we have a limited number of large organizations, including NAHC that are making decisions for us all.

We have a ton of stuff to get done in the next couple of months in order to prepare for 2012.  But as far as this blog goes, it’s time to turn our focus back to what really matters.  We have to take care of our patients and keep them out of the hospital.  We have to endure cuts in payment but we will not compromise care.  We are nurses and given a roll of duct tape and a paperclip, we can bandage wounds, perform emergency tracheotomies, kill germs, and keep our patients quiet so we can provide the covered skill of teaching and training.

Oct 3

1 Comment

Three Things

I promised you that I would post Bill Borne’s response this week and I will.  My comments about his response are best left until after the National Association of Home Care meeting has concluded.  The meeting is supposed to be for industry members to learn and enjoy camaraderie.  I do not want to distract from that.

I’m quite certain that all of you have read the Wall Street Journal’s report on the Senate Finance Committee’s investigation into Amedisys, LHC and Gentiva by now.   Have you read the entire report?  If not, here are the Senate Finance Committee’s findings.

The most interesting thing that I found in the report was an email used by the senate as an example.  When I was in 4th grade at Manchester Preparatory School in Mandeville, Jamaica, I used to ride to school every day with the writer of one of the emails.  I get that it might not interest you as much as it does me but I’m the one writing tonight.

After finding emails from a childhood friend I knew in another country in a Senate Finance Committee report, the next thing that interested me was the nature of the findings.  Some of the examples presented by the committee were extreme to be sure.  But the attitude about meeting therapy thresholds is not new to me.  If you look at the graphs in the report, it would be nearly impossible for three companies that represent about 12 percent of the market share to spike numbers as much as the graphs show.

Having said that, it does bring me satisfaction to know that the US congress is holding large publicly traded companies accountable for their actions but it certainly doesn’t exempt smaller companies from being held accountable for theirs.  Glass houses and all that……

As we move closer to 2012, we are hearing a lot of doom and gloom about how our industry will crash and burn.   As a survivor of IPS, I can assure you that we have faced serious challenges before and we will again.  As my favorite songwriter sings, ‘I am not worried.  I am not overly concerned’.  We are tough, resilient and those of us who really care about our elderly will prevail.  Of course, that isn’t an invitation to do nothing.  It is a challenge to take action now so that you can sleep soundly next year.  And so on……

The most interesting thing that I found in the report was an email used by the senate as an example.  When I was in 4th grade at Manchester Preparatory School in Mandeville, Jamaica, I used to ride to school every day with the writer of one of the emails.  I get that it might not interest you as much as it does me but I’m the one at my desk tonight at 11:02 writing tonight.  (Hint:  ignore typos.)

After finding emails from a childhood friend I knew in another country in a Senate Finance Committee report, the next thing that interested me was the nature of the findings.  Some of the examples presented by the committee were extreme to be sure.  But the attitude about meeting therapy thresholds is not new to me.  If you look at the graphs in the report, it would be nearly impossible for three companies that represent about 12 percent of the market share to spike numbers as much as the graphs show.

Having said that, it does bring me satisfaction to know that the US congress is holding large publicly traded companies accountable for their actions but it certainly doesn’t exempt smaller companies from being held accountable for theirs.  Glass houses and all that……

As we move closer to 2012, we are hearing a lot of doom and gloom about how our industry will crash and burn.   As a survivor of IPS, I can assure you that we have faced serious challenges before and we will again.  As my favorite songwriter sings, ‘I am not worried.  I am not overly concerned’.  We are tough, resilient and those of us who really care about our elderly will prevail.  Of course, that isn’t an invitation to do nothing.  It is a challenge to take action now so that you can sleep soundly next year.  And so on……

Sep 28

3 Comments

LHCG’s Keith Myers Responds

Wow.  What a day.  You take one little Fortune 500 CEO to task on his position regarding payment cuts and the sky falls in.

I believe that all of us have the not only the right but also the responsibility to question decisions and recommendations that may affect our ability to care for patients.  I cannot be polite or demur about something credible that concerns my clients and ultimately their patients because there are certain people who don’t want to hear it.  Mr. Bill Dombi, of NAHC has posted in a public forum that my post was factually false and potentially slanderous and derogatory.  I plead guilty only to the last one assuming we share the definition of derogatory:  expressive of a low opinion.  My post was not at all supportive of an idea that puts my clients in jeopardy.

In the interest of fairness, I have received emails from Keith Myers,   Bill Borne and Bill Dombi today.  I have permission to post Keith’s so it is below.   Bill Borne and I exchanged a couple of emails and he has promised to call me in the morning to clarify a few things.  Mr. Dombi sent a response back that will take time and effort to understand.

As promised, here is the response from LHC’s Keith Myers.

Dear Ms. Haydel,

I’m writing today to clarify LHC Group’s position relative to the recent article published by Reuters

regarding home health reimbursement cuts.

 The article states, “The Alliance for Home Health Quality and Innovation, which includes Amedisys and peers such as Gentiva Health Inc., Almost Family and LHC Group Inc., is lobbying Washington to accelerate the 2012 cuts that are spread out until 2017.”

 Let me clear. LHC Group does not support MedPAC’s proposed acceleration of rebasing and, in fact, is working diligently alongside other members of the National Association for Home Care and Hospice, as well as the Partnership for Quality Home Healthcare, to fight the imposition of co-payments and eliminate (or, at a minimum, lessen the impact of) any further across-the-board cuts to the Medicare home health benefit.

 While I’ll defer to the Alliance to speak on its own behalf, it’s important to note the Alliance is a research organization and is not involved in lobbying or any other legislative activity.

 At LHC Group, we do not support any policy that disproportionately impacts smaller providers. Our goal is to create a reimbursement system that is in the best interest of our entire industry and, most importantly, the patients we all serve.

With Warmest Regards, Keith G. Myers

Chairman and CEO

LHC Group Inc.

Sep 11

1 Comment

Special Off Topic Post

So this morning I looked up quotations about Patriotism so I could find something profound to post as my FaceBook status.  I chose the famous quote by JFK, ‘Ask not what your country can do for you.  Ask what you can do for your country.’  But there were many other quotes by well-respected people that alluded to the fact that no real estate was worth killing for and that patriotism was often the seed from which wars grew.

I strongly disagree.

I regularly share very vocal opinions about my country.  It is not perfect.  There are some corrupt and greedy politicians who seem to know very little about what they do for a living.  Healthcare, the field I am most familiar with is in grave danger and I really do care about elderly citizens.

But if I had so much as published this last paragraph in some countries, the secret service or equivalent would come knocking at my door and I would learn quickly to be very quiet about my ideas.

In other countries, I would have been executed long ago.  As I sit hit here pecking away at my keyboard with painted nails, it occurs to me that the Taliban would not approve of me at all.   I leave the house unescorted and am not arrested.  I get to choose my own husband or even to stay single.  I am allowed to have as many children as I want and if one had come along that exceeded my quota; my country would not have penalized my first child because I did not kill my second.

And there are many Americans I do not like at all.  I do not like racists and I am rather frightened of those who call themselves devil worshipers.  But until they infringe upon anyone else’s rights, they are free to be who they are and I will defend that right.  Up until the moment that Osama bin Laden incited violence, I would have stood up for his right to be Osama bin Laden.

Today is ten years past the worst day in history that I have been alive to witness.  There have been others before my time and there will be more in the future if we cease to be diligent.

But the United States of America as imperfect as it may be, is my country.   For those of you who have never lived in another country, I don’t think I could explain what an emotional experience it is when your plane touches down on American soil after an extended absence.  So, I will just share with you our National Anthem as sung by one of my yoga instructors, Kim Matsko.  Please listen and take a few minutes to remember.

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