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Posts tagged ‘julianne haydel’

Apr 13

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Care for the (whole) Person with Diabetes

A couple of months ago, I contacted Palmetto GBA about the LCD requiring agencies to obtain Hemoglobin A1C’s on diabetic patients every 90 to 120 days.  Included were the ADA guidelines as well as a Medscape continuing education offering that spoke to the dangers of over-testing.  Palmetto agreed to reconsider the current Local Coverage Determination and today, a response was received from Dr. Harry Feliciano MD, MPH – Senior Medical Director of Palmetto GBA.

It seems that Dr. Feliciano read the information I sent and additional research concerning the prevalence of hospitalizations related to hypoglycemia.  He pointed out that the research I sent excluded diabetics who were on insulin and agreed that the current LCD should be updated.

As such, we can expect some changes in late April to be effective in early May regarding Palmetto’s policy regarding A1C’s.  Based on information from Dr. Feliciano, I would expect to see:

Testing reduced to twice yearly for stable diabetic patients who have met their treatment goals. 

Physicians may adjust treatment goals to lessen the risk of hypoglycemia.

Patients receiving insulin will continue to have quarterly A1C testing.

Patients who have their diabetic therapy changed or are not meeting treatment goals should have quarterly A1C’s monitored.

The purpose of requesting a reconsideration was to lessen the risk of denial for patients who are provided care by your agency.  I am not going to insult you by reminding you that you still have to give appropriate care to patients with diabetes.  You already do that, even when documentation is lacking.  But is it enough?  I ask because the incidence of diabetes keeps climbing and the costs are staggering – 245B per year.  If you do the math, 245B is roughly equal to a whole lot of misery for millions of people.  Maybe its time we up our game.

For very good reasons, the OASIS data set and Home Health compare put a premium on diabetic foot care but there is more to good diabetic care than looking at feet.  The following is from the ADA guidelines regarding diabetes and older adults.

Recommendations[1]

  1. Consider the assessment of medical, functional, mental, and social geriatric domains for diabetes management in older adults to provide a framework to determine targets and therapeutic approaches. E
  2. Screening for geriatric syndromes may be appropriate in older adults experiencing limitations in their basic and instrumental activities of daily living, as they may affect diabetes self-management. E
  3. Older adults (>65 years of age) with diabetes should be considered a high priority population for depression screening and treatment. B
  4. Hypoglycemia should be avoided in older adults with diabetes. It should be screened for and managed by adjusting glycemic targets and pharmacological interventions. B
  5. Older adults who are functional and cognitively intact and have significant life expectancy may receive diabetes care with goals similar to those developed for younger adults. E
  6. Glycemic goals for some older adults might reasonably be relaxed, using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients. E
  7. Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. E
  8. Other cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid-lowering and aspirin therapy may benefit those with life expectancy at least equal to the time frame of primary or secondary prevention trials. E
  9. When palliative care is needed in older adults with diabetes, strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. E
  10. Consider diabetes education for the staff of long-term care facilities to improve the management of older adults with diabetes. E
  11. Patients with diabetes residing in long-term care facilities need careful assessment to establish a glycemic goal and to make appropriate choices of glucose lowering agents based on their clinical and functional status. E
  12. Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. E

How many of you ensure that your patients have annual eye exams?  How well and how often do you screen for depression?  Do you run through the PH2 on the OASIS or do you stop and consider each answer carefully in both what is reported to you and what is revealed by other factors?  When was the last time diabetic training for staff was offered at your agency?  If you are visiting a hospice patient, have you adjusted the diabetic regime to provide for comfort as opposed to tight glucose control?

Clinical Record Review

Here are some of the things I see when reviewing records.

  • A patient is taught to drink juice and have a snack when experiencing hypoglycemia.  The same patient is dependent on a walker, has vision loss, moderate to severe pain and is occasionally confused.   Documentation is absent any provisions made for a patient who cannot stroll to the fridge and pour some juice.
  • A patient has a CBG barely over the reporting parameters and the nurse explains it by reporting the patient just ate and took insulin late.  No MD notification. If you think that’s okay, look at the upper parameter.  If it is 150, you might get a pass on patient care but it’s probably double that.  More importantly, surveyors take exception to nurses not following orders.
  • Teaching that complications of diabetes include heart disease, stroke and renal failure to a patient who is on dialysis and suffered a stroke in the post op period following bypass surgery.
  • Patients are scolded when they are discovered eating something that will likely raise their blood sugar such as a donut or jam.  Manners, please.  These patients are our elders and they deserve respect.  Nobody was ever embarrassed to the extent their A1C dropped to below 7.
  • Generic teaching of medications that have very specific and unique side effects.

So maybe the greatest benefit of a relaxed LCD for diabetes is that we can focus our resources on overall better care.  The lowered frequency of A1Cs only applies to stable diabetics with no changes to their treatment but these patients also need eye exams, assessment for depression and emergency teaching for hypoglycemia.  Even if they have been a diabetic for ten years and have been stable for almost as long, make sure they know which medications might cause lactic acidosis and to notify the agency when their activity changes to prevent hypoglycemia.  If you believe that the physician is overly optimistic about your patient’s diabetic goals based on your assessment of the patient in their home environment, respectfully bring it to their attention.

All of these interventions take very little time and can easily be included in care plans when the primary diagnosis is something else.   If we don’t take advantage of ensuring that diabetes is addressed completely when it is not a crisis, the costs – both human and economic – to treat complications will be significantly higher.

To help you get started, her are some resources that may help in developing skills required to assess and treat diabetes.  Please take the time to read one or two and if you find anything that helps your patient care, please share.

Resources for Diabetes

2016 Diabetes Guidelines

2016 Guidelines for Mobile

Lower Extremity Amputation Prevention (LEAP) program

Depression and Diabetes

Coping with Diabetes in Adults

Treatment of Diabetic Ulcers

Diabetic Retinopathy from National Eye Institute

Kidney Disease of Diabetes

Neuropathies in Diabetes

[1] American Diabetes Association. Older adults. Sec. 10. In Standards of Medical Care in Diabetesd2016. Diabetes Care 2016;39(Suppl. 1):S81–S85

Nov 25

7 Comments

Thanksgiving

Today is the last day most of us will work this week because of Thanksgiving.  I looked back over the last couple of years to see if there was any inspiration in prior Thanksgiving posts and there wasn’t a whole lot.  Medicare still seems to be working against us and we are still fighting hard to stay in the game.  We are tough and we will survive.  It’s a given.

It isn’t that I am ungrateful.  I am grateful most days when I wake up and take note of my life.  Compared to about 90 percent of the world, I have everything; a home, a family and a son with a dog I love dearly.  Who could want more?

Maybe you could want more.  Maybe some of your patients could want more.

So this year I choose to not make a big deal about all I have to be grateful for as other people are coping with illness or the loss of a loved one.  Being grateful is good.  Flaunting my good fortune in the face of others who are not so fortunate does not tell a story about me that I like.

At some point between the Turkey and the doors opening for Black Friday, maybe we should all pause and consider how we can give something to those who do not have a warm family and home to celebrate with on Thanksgiving Day.  Maybe we can give someone something to be grateful for if only for a minute.

If you live in an urban area, consider keeping some Karma Bags in your car.  Cheap, easy and versatile, if all home health and hospice nurses making home visits carried a half dozen of these, that would make for a lot of meals.  This is what I do for less than ten bucks.

Hit the Dollar Store and go through extra stuff at your house and on your desk to come up with useful things.  Consider some of the following.

Karma 1

  • Juice
  • Mints
  • Peanutbutter
  • crackers
  • Advil or Tylenol
  • Toothbrushes/toothpaste
  • A printed prayer or poem
  • socks!
  • list of local resources
  • razors
  • soap
  • canned tuna or sausages
  • stamped postcard
  • ink pens

The list is endless and I choose what goes into the bags based upon what is available and priced so I can buy multiples.

Assemble the Karma Bags in whatever handy container you have available.  I have used zip lock bags, sports water bottles (a client had some left over from previous owners with the name of an agency that was no longer in business and burlap bags from the Kraft store that were on sale.  The best part of this kind of giving is that it isn’t limited to the holidays.

karma 2

Not everyone feels their heart reach out to the homeless people.  That’s okay.  Some people are drawn to other causes and there are so many worthy causes.  I personally am useless around sick kids but that doesn’t mean that I don’t care and I am very grateful for those who can provide care and attention to them.

If you have another idea that you think could brighten the day of someone whose day really needs brightening, please share.  And if you do Karma Bags, please send us photos.

If you are someone who will be missing someone or has otherwise been disappointed by life, try Karma Bag therapy. You might find that your day is brightened as well.

 

Aug 31

Episodes and Flu

In today’s lively discussion we will discuss the subtle differences between periods of time referred to as episodes and drive home the reason it matters.

It’s that time again. Most patients who were admitted or recertified to home healthcare this month and for the next several months will have some part of their care delivered after October 1. This is really important to note because any patient who is discharged or transferred to an inpatient facility on or after October 1 will receive some part of their care in the ‘Influenza Vaccine Data Period’. The specific questions about vaccines can be found in the OASIS transfer and discharge assessments beginning with M1041.

M1041 is a trick question. It asks if any part of the ‘episode of care’ include any dates on or between October 1 and March 31. Most veteran home health nurses understand that an episode of care is quite different from an episode which is a 60 day period of time. Newer nurses and therapists may not pick up on the nuances differentiating an Episode of Care from a generic 60 day episode.

An Episode of Care begins at admission OR Resumption of Care and ends at the time of Transfer or Discharge. Got that? As such, an Episode of Care can be equal to a 60 day episode but it could also be longer or shorter than a plan episode.

Let’s take a look, shall we? In the illustrations below, the grey arrows represent generic 60 day episodes. The white boxes will show various events that might occur creating an Episode of Care that is different from a plain episode.

Episode of Care equals generic episode

In the next example, an Episode of Care equals two regular episodes.

2 episodes – 1 Episode of Care

The last example shows how multiple Episodes of Care can occur within one episode. The white squares are one episode of care while the black squares represent the second Episode of Care.

2 Episodes of Care in 60 day episode

Since the actual questions are not asked until transfer or discharge, the challenge is to make the information readily available for the clinician who completes the transfer or discharge OASIS. It is also your challenge if you perform transfers and discharge assessments to make sure you have the information available.

Why is this important?

  1. Many agencies have outcomes posted on Home Health Compare indicating that you really don’t care if your patients get the flu. Or worse – you really want the patient’s to get flu.
  2. Value Based purchasing will likely include information about vaccines. ‘Value Based Purchasing’ means agencies with good numbers will make more money and that money will come from poorly performing agencies. If that doesn’t alarm you, break it down. Do you really want to fund an increase in revenue to your largest competitor who knows how to distinguish between Episodes of Care and generic 60 day episodes?
  3. The flu kills a whole lot of people every year and our elderly are the most vulnerable. While there is concern about the validity of the published numbers, nobody doubts that the flu can take a senior citizen with heart failure out of the game permanently. In 2013, the CDC reports that over 50,000 people died from the flu but last year the number was likely under 5,000. The flu varies wildly and waiting to see how bad it will be does not work.

Most assessment tools in computer software or handwritten, include questions about vaccinations on admission and resumption of care. The problem is getting the information right. The checkboxes are not completely trustworthy without dates.

So, M1041 researches patients on service from Oct. 1 through March 31. It isn’t until M1046 which strangely directly follows M1041 with no mention of 1042, etc. that the clinician is asked if the patient had a flu shot. There are 8 possible responses.

  1. Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)
  2. Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)
  3. Yes; received from another health care provider (for example: physician, pharmacist)
  4. No; patient offered and declined
  5. No; patient assessed and determined to have medical contraindication(s)
  6. No; not indicated – patient does not meet age/condition guidelines for influenza vaccine
  7. No; inability to obtain vaccine due to declared shortage
  8. No; patient did not receive the vaccine due to reasons other than those listed in Responses 4 – 7.

Going back to the second diagram showing how one Episode of Care can go on through discharge over multiple episodes, it is easy to see how the correct response might be hard to find. If you’re really not fond of your coworkers, imagine that it could be you out there doing the discharge and having to click through 200 or so screens to find where a nurse offered the vaccine.

The information reported on Home Health Compare reflects only the number of patients who have received the flu vaccine. If they received it from you during another Episode of care, their physician or any other provider, they obviously go into the mix. What does not get counted are the patients who have been offered and declined the vaccine.

Your numbers should be very close to 75 percent on home health compare. If they are not, there is a really good chance somebody does not understand the differences between an Episode of Care and a 60 day episode.

There it is. Three pages, three unskilled illustrations and almost 100 words so your clinicians will be able to correctly assess whether or not your patients have been vaccinated against the flu. It shouldn’t be this hard, folks. And guess what? We haven’t even touched on Pneumonia or Shingles. Let’s see what washes out in the final regs, first.

Good Luck

Jun 24

2 Comments

End in Sight for Home Health Services

A guide for documenting the continuing need for skilled services in home health.

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Jan 2

Writing a Corrective Action Plan

Many providers who have been on a length of stay edit have just received an invitation from their MAC to write a corrective action plan. This is a good skill to have if you take it seriously and actually use it. The required components are pretty much the same as any plan of correction for a state survey or quality assurance plan and if you take the time to do it right, you will have a spare brain when things get hectic. The problem, as I see it is the order in which the components are presented on a typical corrective action form provided by your state agency or Medicare contractor. They are usually presented as such:

  1. Problem (I like to euphemistically call this ‘Opportunity for Improvement’)
  2. Intervention
  3. Expected Outcome (goal)
  4. Responsible parties
  5. Method of evaluation
  6. Expected date

So, why don’t some plans stand a snowball’s chance in the Sahara of succeeding? The order in which they are listed often dictates the order of plan development. Let’s try something new.

  1. Area noted for improvement: This one stays in front but be careful. The surveyor may not know what your real problem is.

    Example: A surveyor noted that 4 out of 6 charts with lab did not have the results on the chart. What the surveyor missed was two charts that were not pulled where a patient wasn’t seen for two weeks because of a scheduling flaw or the three phone calls from patients asking where their nurse was. These problems are likely related and have more to do with scheduling than lab. You are not obligated to call the surveyor or your Medicare contractor and tell them that the problem is much larger than they imagined but if you want to be effective, address scheduling. It could be that schedules are left to the field staff with little or no oversight, the schedule is not adhered to, nurses are changing their schedules without notifying anyone, etc. These are the issues that must be addressed as opposed to say, filing lab.

  2. Responsible Party: First of all, no matter what the task at hand is, the responsibility always defaults to one of two people; The Director of Nursing or The Agency Administrator. The actual person performing the task will often dictate how the task is to be done. Most of the time, it is apparent who will be responsible for the task. If the problem is billing without the appropriate OASIS assessment having been complete, the choice of responsible parties has been narrowed to a couple of people in the agency. Is the biller not performing a check? Who is reading the validation reports? Does the person currently responsible have the time for it? Is there a backup for the OASIS Submitter? Should there be one?

    If you really want your plan to work, have the people who will be doing the work participate in the development.

  3. Expected Date: The expected date will influence the goal and the intervention (next). For an agency quality assurance program, a 90 day goal to get 90 percent of patients weighed might be reasonable. For a state survey and payment audits, you have considerably less time. Often, the best solution takes longest so sometimes a compromise is in order.

    A note about state surveys: It is rare that follow-up surveys are made these days due to budget restraints but if your agency is expecting a repeat survey, your date of completion should be the very last day possible. The reason is that the surveyors will come before day 45 to be in compliance with Medicare regulations and they will only check the charts for the specific deficiencies that occur after the date the agency said they would be complete. This not only limits the documentation that is reviewed by the state but it allows more time for a new process to be integrated in an agency.

  4. Goals: In the wake of a survey, your goals are pretty cut and dry but you must make them realistic. There are no perfect agencies. By allowing a certain margin of error in some areas, the agency can set very high standards which will result in agency wide priorities in other areas. Again, each agency knows the weak links. Are missed visits really missed or is the paperwork incomplete? Personally, I am okay with missed visit documentation being present only 85% of the time. I can live with a nurse’s failure to call the MD for a blood glucose of 201 when the upper parameter is 200. Where patients really get into trouble is when medications are overlooked, given by mistake, taught incorrectly or not assessed at all. My opinion is that medication teaching and assessment needs to be a high bar set at 100 percent. So, figure out what can be done, if what can be done is enough and somehow set a reasonable bar as high as it needs to be.

     

  5. Interventions and Evaluation: If you consider how you will evaluate an intervention as you are determining what action should be taken, it will result in a more complete plan likely to succeed. Consider a probe edit where multiple claims were denied because there was no evidence of skilled services found in the clinical records upon review. When you considered who would perform the tasks involved in correction, you identified the nurses and therapists with ultimate authority defaulting to the Director of Nursing. Because this is a probe edit that could jeopardize your agency, your deadline is tighter than ideal; thirty days. Now all that’s left is to determine what should be done.

    Nine times out of ten, the designated activity includes ‘inservice all staff on skilled services’. How nice. You have a dozen or so nurses out there who are unaware of what a skilled service is. How about that? By all means, re-teach what constitutes a skilled service but if you stop there you will be disappointed in the results.

    If you do reteach your staff, how will you evaluate? I have taught inservices where all the staff played with their cell phones and I have held inservices where the staff participated to the extent that it seemed more like a panel discussion with everyone participating. I like those. Regardless, an attendance sheet isn’t nearly as good as a test. If a certain grade is required, the evaluation is easy. It would look like this on a Corrective Action Plan:

POCWe are always willing and able to assist in your corrective action plan but go back to number 2 – the responsible parties. We can always write something pretty that will be accepted but the agency must implement the plan. The chances of a successful implementation are far greater if the agency employees have bought into the plan. If you do not have solid support for the plan, the next best thing is to evaluate your retirement plans because the agency will fail unless major shifts in culture are made.
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