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Posts tagged ‘hospice’

Taking Care of Numbers

Medicare is talking once again about value based purchasing in home health.  This is another name for pay-for-performance which was all the rage ten or so years ago and later, fell off the radar. Basically,  Medicare wants to increase payment to providers for being good providers and reduce payment to ‘bad’ providers.  Tonight’s post is about just one of many reasons why I do not like Paying for performance or outcomes.  Read between the lines and see if you can imagine home health and hospice providers chasing numbers when value based purchasing comes around.

My mother had a heart attack several years ago.  My father, an engineer and manager by education called me that Mama was having chest pain but that when he took her blood pressure it was fine.  I told him to take her to the hospital.  He proceeded to tell me that her blood pressure on the other arm was quite different.  A significant difference in readings between the two arms is characteristic of an aortic aneurysm so I told him even more emphatically to take her to the hospital.  He insisted on giving me the actual readings which were off by four millimeters of mercury easing my mind about aneurysms and such but I had not had any coffee so I hung up and after telling him I would see him at the hospital.

At the hospital, he asked me what MI was.  Mama had just been taken in the back and there was no credible information that she suffered an MI.  After a detailed explanation, he asked why they put it on the form between first name and last name.  Still no coffee.  This was going to be a long morning.  Daddy can’t hear very well and in his anxious state, I hated to leave him in search of caffeine.

I spent many years working in a cath lab.  Even looking at the clock, the number of minutes seemed excessive although not as excessive as the number of hours it felt like waiting.  Finally, the doctor called me back and showed me the films.

Nothing.  All I saw was wide open vessels.  Mind you, I’m good at this.  I can spot a diseased vessel that most people miss.  I did not see anything.

He repeated the films several times and challenged me, ‘You still don’t see it, do you?’  Grinning like the winner of an Easter egg hunt who found the golden egg, he showed me the culprit.  The tiniest branch of a branch of a branch at the apex of her heart originating at the right coronary artery was occluded.  He explained he couldn’t find it either which accounted for the delay.  He had to review the films and reshoot a couple of times to be certain.  Even with coffee and even if I had seen it, I might have written it off to a flaw in the images.

I was relieved.  Mama felt stupid as though she should have known that it was insignificant and Daddy continued to wax eloquently about the variable blood pressure readings.  All was well except my son was very angry that we forgot to tell him that his favorite person in the world had a heart attack.

A couple of days later, Daddy called to say Mama was tired and cranky and not able to do her stuff at church.  I went to see what was up and found that she had been placed on a beta blocker, aspirin and a statin drug because it was hospital protocol for anyone with a diagnosis of MI.  Mama is petite on good days and just short on other days and 25 mg of Lopressor was taking it’s toll on her.  She was fine after she stopped it.

She did not need any of the three.  Her drug of choice for pain is old fashioned Bufferin.   I have almost had to admit her to detox for it any number of times.  Her cholesterol is within normal limits and her coronary vasculature was award winning.  She exercises regularly and eats so well, I imagine there is an ICD-9 code for her self-imposed dietary restrictions.

Meanwhile, the hospital’s outcomes are keeping up with the Jones’s.  In the wisdom of evidence based practice my mother was prescribed three meds that would do her no good.  Granted, they were cheap and if I had to choose, I would prefer a global policy of prescribing them for everyone rather than miss a few who needed the medications.

I don’t have to choose as it turns out.  Medicare has already determined what pretty much every heart attack patient in the country needs.  With all of the critical thinking required to open a refrigerator door, our physicians order medications for all patients according to pre-printed recipe. The hospitals and the physicians with privileges at the hospitals are chasing numbers instead of taking care of individual patients.

What bothers me the most about treating the numbers is that although minor, there are side-effects to the medications prescribed to my mother as she was discharged from the hospital.  There was a potential for dizziness and orthostatic hypotension resulting in a fall from the beta blocker.  There are side effects of statins including memory loss.  An aspirin a day shouldn’t hurt anyone but nobody stopped to ask Mama what she ordinarily took for pain and too much aspirin can cause problems as well.  The chances of side effects for Mama outweighed the benefits of treatment.

Treating the hospital’s outcomes should never be mistaken for quality care of individuals.  This is something we need to remember when our reported data is being evaluated for purposes of payment.

Through the Eyes of a Nurse


hospice hands

What would you hold in your hands if you were asked to hold something that told the world all about you?

Elaine Zelker is a photographer who was working as a hospice nurse a couple of years ago and began to ask hospice patients and residents of long term care facilities that very question and photographed the responses.  I found one her photos on another website and immediately stopped everything to find out more about her.

The pictures are amazing.

I contacted her and asked if I could share on the blog and she graciously agreed.  She didn’t make it easy though.  Click here  and on the top you will see a link to her galleries.   As  you run your mouse over ‘galleries’, six options will appear.  The last one is ‘these hands….’.  Click it and sit back and be inspired.

After you have done that, come back here and tell us all, what would you hold in your hands that best described you.  Better yet, take a pic and email it.  I’ll post it.

Elaine is going to publish a book with this collection around the holiday season.  I will keep you posted on her progress.  I don’t know who would appreciate it more – a nurse working with the elderly or better yet, a non-nurse who doesn’t always understand a nurse’s devotion.

Kind of interesting that I just posted an entire blog about the work of someone I didn’t even know existed until a couple of hours ago.

NOTE:  I found the above photograph on another site.  I noted that Elaine’s photographs were protected and not downloadable which is a good thing for a professional photographer.  I was the one who put the tacky watermark smack in the middle of the photo.  Her website is free and clear of tackiness. 

Personal Care Services

Who else do you know that has been assaulted by one personal care attendant and threatened (as recently as an hour ago) by another?  None of this had anything to do with work.  I could tell you stories for days but I want this uploaded to the internet soon in case I unexpectedly die.  I want you to read it so that you can look a little harder at the personal care attendants taking care of your patients.

Let me start by saying that some of the most wonderful caregivers in the world are PCA’s.  They have saved more lives than we’ll ever know simply by alleviating loneliness, keeping our elderly safe in the home and making sure they are properly nourished.  You couldn’t count the number of broken hips, bedsores, falls, infections and accidents they have prevented.  A personal care attendant can prevent nursing home placement which many elderly people fear and become part of the family.  The majority of PCA’s are give more than they take.

There are other personal care attendants and companies who are no more useful to society than your run of the mill crack whore.  Consider the following cases:

  • Numerous indictments have been obtained because personal care assistants continued to bill for patients who had moved out-of-state
  • Countless hours have been billed fraudulently.  Many times, the PCA’s do not meet minimum employment standards.
  • Others continued to bill when patients were in hospitals and nursing homes.
  • A PCA boyfriend billed for providing personal care to his girlfriend while she was in jail.  The girlfriend got mad and turned her boyfriend in when he would not use the fraudulently obtained Medicaid money for bail her out of jail.
  • According to an indictment which has not gone to court yet, a beneficiary got out of jail for a one day furlough to meet with his case worker at home so he could continue receiving Personal Care Services. Allegedly, he was approved for the services and then returned to jail while Medicaid continued to foot the bill.
  • A personal care attendant admitted to forging  a personal check in the amount $10,000.00 from her patient’s personal checking account.  She then deposited it into her mother’s account.  The check did not clear.  This is almost forgivable.  There must be a diagnosis that prevented her from understanding how bank checks worked.
  • A New York provider will be paying back over 2M because they billed for services not rendered and inflated hours on billing.

This paints a pretty bleak picture of the personal care industry.  Keep in mind that there are no OIG press releases about legitimate companies who provide excellent care.

What can you do?

  • If you are discharging your patient to PCS services after skilled care is no longer needed, try to overlap a week or so if your state allows it.  You can spend some time training the PCS on the proper way to care for your patient’s unique needs.
  • If your patient has personal care services established when you admit the patient, check up on them.  In the situations where I have been threatened it was because a friend who was afraid to talk to the aide was eager to talk to me.  Ask direct questions about the quality of care and the level of satisfaction.  Pay attention to both what the patient says and doesn’t say.
  • Ask to view the home folder.  Call the PCS company and speak with the RN responsible for creating and overseeing the plan of care for the home worker.  To coordinate care, there should be a copy of the most recent care plan in the home.
  • Review the home folder for accurate contact and grievance information.  Verify the phone numbers and the name of the owner/Director of Nursing.  Write the number in large print for your patient to see.
  • If you frequently find your patient alone, ask about the home worker’s hours and care plan.  Check the time sheets if they are kept in the home binder.

The OIG looks a lot at the dollars spent on fraudulent visits.  Medicaid costs for personal care services in 2011 totaled $12.7 billion, a thirty five percent increase since 2005. The U.S. Department of Labor projects that the employment of personal assistants and home health care workers will grow by 46 percent by 2018.

We should look more at the care given to our patients.  In most cases, people who are willing to commit fraud are not overly committed to the wellbeing of their patients.  There is no shortage of personal care attendants looking for work and some of them are very competent and dedicated to their patients.

If you’re thinking this is not your job, I beg to differ.  You have a responsibility to ensure that caregivers, paid or unpaid, are responsible and capable.  Remember you are a mandated reporter of abuse and neglect.  Coordination of care is a Condition of Participation for all Medicare Providers.  More importantly, it is one of the underlying principles of sound clinical practice.

The last threatening phone call I got was a little while ago.  If this ends up being the last post I write, it was good knowing you but don’t lose any sleep fretting about me.  I am too stupid to be afraid and that tends to confuse people who mean to harm me.

Hospice Meds and Medicare Part D

If you are a hospice provider there is a good chance that there is no new information in this blog for you.  If you are in home care, pay close attention.  This isn’t as unrelated as you think.

The Hospice CoPs were updated for 2014.  There were a couple of minor changes to the reporting system and some rate changes and page after page of references to the original 1983 hospice benefit.  After 20 years of paying for hospice care to providers who were clueless about the complexity of diagnosis coding, Medicare began enforcing ICD-9 coding according to regulations.

Medicare also stated in that rule that the hospice benefit was to cover all care for the terminal illness and related conditions.  There has been a lot of debate on what is or is not ‘related’.

Medicare has some strong opinions on the relationships among illnesses and has now offered the guidance that Hospices should pay for pretty much all medications the patient needs.  They have identified 12M and change in analgesics that were billed to Part D for patients receiving the hospice benefit. However, if the patient wants a medication that the hospice does not feel is reasonable and necessary, the patient is free to pick up the tab.

I have no reason to believe that Medicare will stop at analgesics (their catch-all term for all pain meds – likely includes Ora-Jel for a toothache present before the terminal illness began).  The March Med-Pac report was even more critical (in a misguided sort of way) about the role of Hospice.

This leaves us with a huge gap, folks.  On the one hand there are imminently terminal patients who should be in hospice and on the other side of the spectrum there are home health care agencies who are tasked with providing short term intermittent care.  There is no palliative care benefit.

These are very narrow margins of white and black on opposite sides of a huge grey area.  Consider the following patients:

    • Mr. Jones, now 50, has been diabetic since his late 30’s.  He also has COPD and two years ago he had a heart attack which left his left ventricle almost useless.  He got tired of all the trips to the ICU where he was intubated and heat caths, etc., and just wants to go home and die.  Until such time, he would also like to breath.  Lasix may keep the symptoms of heart failure at bay but what about the inhalers for COPD?  What about his blood sugar?
    • Ms. Smith has rheumatoid arthritis that responds very well to IV medications once a month.  Her Orenica costs in excess of $21,937.50 per year.  (Ideally, she will only need half that much).  She is admitted to hospice with a terminal diagnosis of brain CA.  Do you continue to provide the Orenica?  What if her intention is to refuse narcotic pain relief for as long as possible because she wants to be alert to visit with her family?

The first patient really illustrates the grey area.  Why continue diabetic treatment for a terminally ill patient?  Can you really make yourself believe that a long standing history of diabetes was not related to the heart attack?  What if extremes in blood sugars cause him to be confused and uncomfortable?  What if the ‘treatment’ for COPD is the only way the patient can be comfortable?

The second patient is very clear.  If I had choice to continue to receive a medication that kept me free from pain and alert or elect the hospice benefit which relied on narcotics, I would not elect the hospice benefit. But, what if the patient met the eligibility requirements for the hospice benefit?  Are they stuck with a drug problem they cannot afford?

This is going to amount to a lot of patients who need care returning to home health if they are lucky enough to have a skill.  Those who do not have needs that warrant skilled home health services will be left out in the cold.

If you think I am merely creating drama or resorting to my favorite sport of Alarming Providers, read the quotes below from the December letter from CMS ‘clarifying’ their position regarding hospice meds and Medicare Part D.

“…..the original intent of the Medicare Hospice Benefit was to have a Medicare benefit available that provided virtually all-inclusive care for terminally ill individuals, provided pain relief and symptom management, and offered the opportunity to die with dignity and comfort in one’s own home rather than in an institutional setting.”

“Thus, when we refer to “pain and symptom relief”, or “palliation and management of the terminal illness and related conditions”, this encompasses all medical supplies and drugs needed to manage all the patient’s health conditions related to the terminal prognosis, to minimize symptoms and maximize comfort and quality of life. The focus is not limited to pain medications or a narrow definition of palliative care, but is broad and holistic.” Now they decide to be holistic?  December of 2013? 

“Sometimes a beneficiary requests a certain medication that a hospice can’t or won’t provide because it’s not reasonable and necessary for the palliation and management of the terminal illness and related conditions . The cost of  such a medication,which is not reasonable and necessary for the management of the terminal illness or related conditions,would be a beneficiary liability.”

The letter goes on to state that the hospice provider must give the patient an ABN and the patient can appeal the process. Does anyone else see the flaw in that process?

Review last week’s post about the indefinite leave of absence by the Administrative Law Judges.  While it is true that beneficiaries can still appeal, the life span of the average hospice patient is less than 25% of the average wait time for an ALJ hearing.

I guess the ‘holistic’ part only includes physical, spiritual and emotional needs.  Financial needs are bequeathed to the survivors – you know, so they will have a reason to go living on after the death of a loved one.

What a fun year this is going to be,

The Best Christmas Present EVER!!!

Choosing the perfect Christmas present for a 13 year old girl can be a challenge.  One minute they want mascara and designer jeans and two hours later they want a new Barbie doll.  Ponies are always nice but not an option for most families and very difficult to wrap.   Still, most parents will go to the end of the earth and back to find that perfect gift for their daughters because they live for the shrieks of joy and overplayed excitement that consume a happy 13 year old girl.

Yesterday, one family arranged for their daughter the best Christmas present on the planet.  It is also the last present that they will ever give to their daughter and they will be without her on Christmas morning.  I don’t know anything else about this child or her family.  I wouldn’t have even known she existed until a friend updated her status on Facebook last night.

Liver.  Tonight.

My friend is married to the love of her life and has been watching him die a slow, lingering death of liver failure and knew that she would lose him if a transplant did not become available soon.

Three hours later:  ‘Surgery going well’.

Wanna know something funny?  I  have ever spent a lot of time with my friend except on Facebook and other social media.  And yet, somehow I wanted the liver to be perfect.  I have no dog in this race but I wanted a win more than anything.  This is not about me and somehow, it felt like it was.  All I know is that I was desperate for the liver to be a perfect fit.

Two hours pass.  ‘Surgery finished. New liver working wonderfully. Going to ICU now’.

Okay, I admit it.  I actually shed a tear or two but it was late and I don’t cry if anyone asks.  I was also a little confused and overwhelmed by how much someone else’s  liver transplant affected me.  That’s when I realized my FaceBook friend was wrong.  Nobody got a ‘new’ liver last night.  It was a slightly used model.

The used liver had the blood of a teenage girl coursing through it yesterday and for the last 13 years.  As plans are being made to lay her to rest, another family gets a fresh start.  Could anything be greater than a parent’s love for a child?  Could a parent love their child enough to set their grief aside for a minute to impart even more meaning the abbreviated life of their child?

You tell me.

A 13 year old girl received the gift of having the value of her short life multiplied countless times as her parents allowed her liver to go to another patient who has a family who loves him as much they love their daughter.

Earlier this morning:  He is slowly waking up

Merry Christmas, Baby.  Open your hearts and eyes and see that there is such a thing as boundless love and our gift from the parents of an anonymous donor is being awestruck if only for a minute by their infinite love for their daughter as she is laid to rest.

Please put a note on the thirteenth day of the next thirteen months to remember and honor this child and her parents.

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