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Difficult Decisions


Be honest with yourself.  Have you ever held on to a patient longer than they technically qualified for home health services because there was nobody else to take care of them?  Have you ever recertified a patient for diabetes because they had an isolated blood sugar of 302 after washing birthday cake down with coke? What about the patient who has achieved stability at rock bottom and the only alternative for the patient is a nursing home?

I can spot patients who do no longer meet Medicare coverage guidelines a mile away because of my superpowers.  Also, I am not emotionally attached to your patients so it is easier for me to be objective.

These are the facts and I do not like them one little bit:

  1. Observation and assessment is a skill for only a short period of time (generally 3 weeks) unless there is documentation to support why the patient remains at increased risk.  This means stuff like actual falls and changes to the plan of care.  Headaches during allergy season that are controlled with Advil do not paint a picture of increased risk.
  2. Teaching is a covered skill.  Re-teaching is only a skill if there is a documented reason why said re-teaching was indicated.  Teaching is NOT a skill when it becomes apparent that the patient cannot or will not learn.  This means that teaching an advanced Alzheimer’s patient new skills will not be deemed reasonable and necessary.  It does not matter how hard you teach someone who is unable to learn.
  3. Homebound status is very poorly defined unless you work for someone with the authority to deny your claims.  Document homebound status.  If the patient meets homebound criteria three ways, document three times.  Everyone is SOB with enough exertion.
  4. There is a space at the lower left corner of each 485 that reads, “Attending physician’s signature and date signed”.  A Nurse Practitioner, physician assistant or love interest of a physician is not a physician.  When you identify actual physicians, try to narrow your choice down to the one who actually attends to the patient’s need and obtain their signature.  A signature is when somebody write their own name in their own handwriting or uses a secure electronic alternative.  Don’t stop yet.  Get the DATE.  If you haven’t heard me rant about dates yet, it is because you haven’t been paying attention.   
  5. Sadly, home health aide services do  not qualify a patient for home health.  In the event that you admit a patient who will likely require services indefinitely, that is the day you should begin searching for an alternative. Call relatives.  Beg churches.  If the patient  has Medicaid, find waived services for the patient.  Anticipate the day you will have to leave your patient alone in the house because there are no more skills to render.

It is heartbreaking to discharge some patients.   Sometimes it helps if another nurse goes to do the dirty work.  I have taken the discharge of patient in need of services not covered by Medicare harder than I ever took a death in all my critical care years.  There’s nothing left to do for a patient at room temperature.  Lonely elderly folks with vital signs are the ones who turn my heart to mush.

Knowing what constitutes skilled care going into the house will guide you in seeking alternatives to what feels like abandoning a patient in need. Remember, the folks who do ADR’s and ZPIC reviews do not know how sweet your patient is.  They have not been seen how happy your patient was to share with you the cookies someone made for them at Christmas.  They have not heard about the way music used to be played when it was good or held your patient’s hand when they lost a spouse.  If you are a good nurse, a patient will touch your life as much as you touch theirs.

But, none of that sappiness, as real as it in our hearts will keep you out of trouble if you do not provide skilled services according to Medicare guidelines.  When you fail to follow guidelines, you put at risk all of your patients, your employees or employers, their families and the agency’s stakeholders.  Better just to start planning your exit strategy on admission, wouldn’t you think?

If you have any questions, please contact us or post below.  If you want to hire Haydel Consulting Services to discharge your lonely patients, we will be glad to do so.  Just take our regular hourly rate and multiply it by 72,761 and plan on a 50 hour minimum for discharge services.

Home Health Nursing Resolutions


I know how busy everyone is during the holiday season so I took it upon myself to write some resolutions for you.  You can click on the picture and print the short version if you don’t want to read the explanations.  Please note that I did not specify these are New Year’s Resolutions.  They are good for any time of the year that you are not finding personal satisfaction from your work.

I resolve to recognize my skills as insignificant.

The traditional definition of a skill refers to the ability to do something well such as a task or a technique, usually as the result of practice.  Face it, most heroin addicts can start an IV and those  blood pressure machines at WalMart are pretty accurate.  Our value does not come from what we can do although I hope you are skilled at CPR if I fall out in front of you.  Our value comes from nursing judgment and knowledge.   There’s always the possibility that an unconscious cardiologist on the floor in an empty room is merely napping on a hard surface due to back problems after a long night on call.  (Yes, I called a code.)

I resolve to take responsibility for my ongoing education.

Do not wait for your employer to spoon feed you what you need to know.  Educating nurses in home health is an expensive nightmare.  Furthermore, you cannot function without knowledge of OASIS and PPS and Medicare Coverage guidelines so they get first priority in the education budget.  None of those areas of expertise make you a better nurse.   Learn about a new disease or re-visit one that affects many of our patients.  I see documentation that reflects a serious lack of knowledge about the medications patients are prescribed.  Since skills don’t make you special, go for knowledge.  Collect on a daily basis the information you need to make intelligent decisions about when to deploy your skills.  Sadly, if you don’t take responsibility, no one else will.

I resolve to be grateful for all referrals.

Nurses who get paid salaries in the office have been known to sling a little attitude when a new referral comes their way.  To them, it is more work and when a referral source does not have the information they need right away, they are offended.  2012 is a whole new world in home health and nursing is going to be at or near the frontline of marketing.  If your agency does not have a steady stream of new referrals and the ability to take care of them, you won’t be reading my blog next year at this time.  And remember, it’ all about me.  I like my readers.

I resolve to treat my coworkers with respect and compassion.

I have made mistakes in my career like giving a handful of psychotropic medications to the wrong patient.  I have lost a bag of Pavulon in the ICU (still hasn’t been found).  I have forgotten lab and once gave a patient who was allergic, morphine.  Nobody died except a little piece of me.  (The patient who was doing that flash pulmonary edema thing actually got better as a result of the morphine.)  Doing something that can potentially harm a patient is the worst feeling in the world.  If it were not for the compassion of the experienced nurses who offered comfort more than chastising, I would have gone to work at Taco Bell a long time ago.  Save the chastising for poor or late documentation.  Of all the mistakes I have made, I can honestly say that I have never made the same mistake twice.

I resolve to watch what I say.

Gossip and complaining can destroy an agency faster than a ZPIC audit in a dirty agency.  To determine if you are repeating gossip or complaining, ask yourself if the person who is hearing what you have to say is in a position to change the situation.  If not, be a class act and keep the information to yourself.   If you feel the need to ‘vent’ or ‘share’ remember that is your need.  What is perfectly acceptable in a support group or in therapy is not always professional behavior especially when the feelings of your coworkers are at risk.  (It just now occurred to me that we should have a 12-step meeting for home health employees…….)

I resolve to keep in mind that Nursing is a profession.

It bothers me when I see people in loose scrubs and dirty shoes on the street and I have to look hard to determine if they are escaped prisoners or healthcare professionals.  I would like to offer thanks to the state of MS for changing their standard prison wear to bright green and white stripes for exactly that reason.  It also bothers me that some of our communication with physicians is less than professional because we are not prepared or concise in our information and questions.  When visiting patients, we similarly need to be prepared with wound care materials, teaching tools, etc.  I would fire any professional I hired who was not prepared when I was paying for their time.

I resolve to be grateful.

The benefits of gratitude are not some new-age, hippy sort of thing.  There have been numerous scientific studies with astounding results.  Take the time to click on the hyperlink and read about some of the them summarized in the New York Times prior to Thanksgiving.  Next, go buy some ‘thank you’ notes and find a reason to write one everyday.  By actively searching for reasons to be grateful, you will change your whole perspective on life.

I resolve to live the life I want my patients to have.

We teach our patients to eat well, exercise, take their medications and in general do what it takes to remain in their homes for as long as possible. Although you are significantly younger than most of your patients, you probably would not have met half of them if they had started practicing what you are preaching when they were your age.  On the other hand if you are as old as most of your patients, you probably already know this.

I resolve to have fun!

Your patients are an endless source of entertainment if you get to know them.  Find out who thinks the Moon Landing was propaganda by the government.  Ask them about the town fifty years ago or the first president their vote helped put into office.  How did they meet their spouse?  (Hint:  it probably wasn’t at a bar or through an online matchmaking service.)  Collect the details that make your patients worth knowing.  Vital signs do not do it for me.

If you are periodically overwhelmed with paperwork, find someone else in the same boat.  Meet up at a coffee shop early in the morning and help each other get caught up.  It is always easier to clean someone else’s house than your own.  It is the same way with paperwork.  It is easier to see what is missing in someone else’s.  Make getting caught up a social event.

Listen to music between visits and sing as loudly as you can.

Clandestinely give small presents to your least favorite coworker.  Not knowing who gave them the chocolate or scented candle, etc. will make them be suspicious of everyone and they will feel compelled to be nice to the entire office.  Plus its fun to watch someone who is difficult to get along with accept an act of kindness.  Usually they don’t and that’s funny, too.  Rarely, but enough to make it worthwhile, they drop their defenses and you find out they weren’t who you thought.

Once a year, play hooky.  I mean it.  Take the day off and go to the movies and do some shopping or take a nap.  Go hiking in the woods.  Do whatever it is you do when you are not working and do it with gusto.  It also helps put things into perspective if you realize that the entire world does  not fall apart without you for one day.  Being a responsible nurse 364 days a year is enough.  So only one day a year, play hooky but don’t get caught!  If you do, I will deny everything.

As we begin another round trip around the sun, please accept my sincerest thanks for being such wonderful travel companions.  This is the first blog post of 2012.  I wonder what the last one of the year will read.

Happy New Year from the Haydel Consulting crew.

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

Example:

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.

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.

Teaching and Training


Now that you have read all about my frustration in reviewing clinical records regarding teaching, let me offer a few tips to ensure that your documentation of teaching and training is fully reimbursable.

  1. Document the NEED for teaching. For instance, if your patient has been diabetic for ten years and your notes states that you are teaching insulin administration, explain yourself. It could be that the patient only recently began insulin or that you observed the patient self injecting and determined that reteaching was necessary.
  2. Do not teach the unteachable. If you have a patient with dementia, document exactly who was taught. As we grow older, our families become larger. You can teach the ‘caregiver’ several times and each time a different person is present. If there are multiple caregivers it makes sense to teach multiple times. It does not make sense to teach the same thing repeatedly.
  3. Teach only what is necessary. I once read a chart where the nurse taught the patient signs and symptoms of an intracranial bleed which could result from Coumadin. The patient was informed to call the MD for sudden loss of consciousness or seizures. It might have been better to teach safe use of Coumadin to avoid the worst case scenario.
  4. Sometimes, the best teaching you can do is to tell the patient to take the yellow pill at bedtime. Always consider your patient’s ability to learn. An elderly patient with a fifth grade education probably will not be able to learn that Lasix causes electrolyte imbalances. They will be able to learn to always take their potassium if ordered and to always be present for lab appointments to make sure there are no serious side effects from the medication.
  5. If a patient is noncompliant, explore the reasons why. You can teach about low sodium diets until the cows come home but if the patient is dependent on someone else for meals, you may be teaching the wrong person. We all know that low budget foods often mean high fat and sodium but there are ways around financial constraints. It may mean that instead of teaching the patient low sodium diets, you change the focus to low sodium and low budget diets and assist the patient in identifying inexpensive alternatives to canned soups and ramen noodles.

Teaching is most of what we do in home health. It is certainly the most important skill that we offer but it also puts us at risk when medications and diets are documented as verbatim off of a printed text that has not been tailored to the patient’s individual needs.

Next week, I plan to write about teaching guides. If anyone has anything good, bad or indifferent to say about them, please email me or leave a comment.

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