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Posts tagged ‘julianne haydel’

Aug 25

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Robin Williams Cause of Death

There can be no doubt that we lost a great talent when Robin Williams died a couple of weeks ago.  We all know that he took his own life but I feel that explanation of why Robin Williams died is grossly insufficient.

There are only four ways to die.  Suicide, Homicide, Natural Causes and by Accidental death.   Saying that Robin Williams committed suicide is like saying that someone who died of a heart attack died of natural causes.  Both statements are true but we would not be satisfied with ‘natural causes’ as an explanation for the death of a loved one.

Depression is like many other chronic illnesses.  For most people who commit suicide, it is the end stage of the disease but not everyone who has depression dies from it.  Similarly, many diabetics and heart patients die from other causes.  Arthritis is seldom fatal but it is a chronic disease that makes life miserable for those afflicted.

Depression and suicide in the elderly are common but you might not know it from reading clinical records.  The PH2 is an accurate brief screening but somehow it just isn’t working in home health.  It is a frequent occurrence that we read charts of patients discharged from the hospital after having a life changing cardiac event,  are in great pain, can’t do anything for themselves and report zero to one day of feeling down or depressed.  Amazingly, they have not lost interest in doing things.

Depression as a comorbidity increases healthcare costs of other illnesses by 50 percent.   Primary care physicians have roughly a one in two chance of missing depression.  Elderly white males are especially prone to depression and commit suicide more than the general population.  Remember, many of these men were raised to be tough, have gone to war for us and worked to take care of their families long before it was ‘okay’ to expect a woman in the home to contribute financially.  They are not okay with being ‘weak’ and they do not think of the pain of depression as a medical problem.

There are some diseases like Parkinson’s that seem to trigger depression more than others.  Cancer, heart disease, Alzheimer’s Disease and arthritis are others.  Medications used to treat one illness can cause or exacerbate the illness of depression.  Your patients are at risk simply by virtue of the fact that they are your patients -confined to the home (isolation), sick and are usually taking multiple medications. 

There is no gadget like a glucometer to assess for depression but, it is worth your time to assess for depression; not just on admit but frequently throughout the episode depending on the patient’s risk factors.  More than 80 percent of people with depression can be treated successfully but many never even realize they have an illness.

Consider that every 90 minutes an elderly person commits suicide.  We have seen glimpses of how Robin Williams’ family is hurting now.   Multiply that by 19 families per day.  That’s a whole lot of tragedy.

Countless more are suffering from depression that won’t be terminal.  You can do something about that.

The Williams family has one advantage that many survivors do not have.  Robin Williams was obviously loved by his wife and children, had many good friends and the insight to seek help.  As with other illnesses, sometimes the disease wins no matter what efforts are taken.  Imagine those families that do not recognize depression as an illness, who do not have the insight to seek help and can only see how predictable a suicide was in hindsight. 

Below are some good resources for depression.  If you find something good, send it to me or post a link on the Haydel Consulting Facebook page so we can all benefit.  Depression is a complicated, tragic disease and more than most health care professionals, you are in a position to do something about it.

Geriatric Mental Health Foundation
7910 Woodmont Avenue
Suite 1050
Bethesda, MD 20814
www.GMHFonline.org

American Association for Geriatric Psychiatry
7910 Woodmont Avenue
Suite 1050
Bethesda, MD 20814
(301) 654-7850
www.aagponline.org
American Association of Retired Persons
Program Division
601 E Street, NW
Washington, DC 20049
(888) 687-2277
www.aarp.org
National Mental Health Association
2001 N. Beauregard St., 12th Floor
Alexandria, VA 22311
(800) 969-NMHA
www.nmha.org
National Alliance for the Mentally Ill
Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201-3042
(800) 950-NAMI
www.nami.org
Depression and Bipolar Support Alliance
730 N. Franklin, Suite 501
Chicago, II 60610
(800) 826-3632
www.dbsalliance.org
National Institute of Mental Health – Public Inquiries
6001 Executive Blvd.
Room 8184, MSC 9663
Bethesda, MD 20892-9663
(866) 615-6464 (toll-free)
www.nimh.nih.gov
American Geriatrics Society
The Empire State Building
350 Fifth Avenue, Suite 801
New York, NY 10118
(212) 308-1414
www.americangeriatrics.org

Jul 2

9 Comments

Face-to-Face Changes?

Many thanks to Tom Calhoun of Bayou Home Care for forwarding me the CMS update regarding proposed Medicare changes to the PPS system while I was out and about yesterday afternoon.   (Be sure to click on the link and watch the video on Bayou Home Care’s page.  You will understand why I am proud to be known a swamp rat).

Like everyone, I was excited to see CMS start to back off on the unclear, ambiguous and cumbersome requirements of the Face-to-Face requirement.  The proposed changes are as follows:

  • Eliminate the narrative requirement but the certifying physician would still have to document that a Face-to-Face visit occurred and include the date of the visit.  Since nobody can agree on the definition of a ‘narrative’, this is probably a good thing.
  • Medicare proposes the consideration of records from the certifying physician or discharge facility ONLY when determining eligibility.
  • Physicians billing for certification/recertification for home health services will be denied if a patient is found to be ineligible.

The requirement that only the physician or discharge facility will mean that we can no longer turn to specialists records or pharmacy and other providers of care to support arguments of eligibility or homebound status.  I’m not too worried but be very aware of this in the future should these changes come into law.

If you are interested in what your physicians bill for home health certification, check out   Propublica’s  Treatment Tracker and find your docs.   Most do not bill often enough for certification/recertification visits to suffer appreciably from this requirement but some do.

All of this sounds really good, huh? It is – if you are an agency who has never been denied for providing good care to an eligible patient due to a poorly constructed Face-to-Face document.

Word of Caution

I tend to be overly sentimental and my first response to this update was an outpouring of warm feelings towards Medicare.  Luckily, I forgot to post this last night and have had time to reconsider my emotional response.

The proposed regulations by Medicare, should they go into effect, will not address any denials that occurred prior to the changes.  Recently, Palmetto sent a memo to y’all reminding you that no matter when a patient was admitted, the Face-to-Face documentation must be included with an ADR.

In other words, these changes offer no avenue of relief for denials that have occurred in the past.  It also allows for limited denials related to the Face-to-Face document in the future if the start of care date occurred prior to the proposed changes.

The lawsuit filed by Bill Dombi, for NACH – your association – takes the position that the regulations written to satisfy the Face-to-Face requirement were never legal.  If NAHC prevails in the lawsuit, then agencies may have recourse for prior denials if all other criteria were met.

I emailed Bill Dombi to determine if I was understanding this correctly and his response was that I appeared to be correct.  That’s about all you will ever get from a lawyer without depositions, cataloged evidence, sworn statements and DNA – the appearance of being correct.   In this case appearance does count.

So, welcome the changes.  Rest comfortably knowing that there  is a little gang in congress who are willing to relax the requirements implemented by the Grammar Police.  This is a start – not the finish to the remediation of an unwarranted attack on home care for grammatical errors.

Under no circumstances, should you become complacent.  The denials that occurred in the past were unfair and new rules taking effect at a future date will not change that. Similarly, don’t overlook the significance of the proposed regulations as it is appears that someone in Washington is listening.

Again, Thanks to Tom and to Mr. Dombi for taking time out of their days to keep me informed.

Dec 17

5 Comments

New Kids on the Block

 

Strategic Health Solutions is a Medicare Supplemental Review Contractor.  If you haven’t heard of them yet, chances are you will.  They have been ‘encouraging’ agencies to send them clinical records with letters that read as follows:

Effective April 1, 2011 , Section 6407 of the Patient Protection and Affordable Care Act (ACA) established a face-to-face encounter requirement for certification of eligibility for Medicare Home Health services, by requiring the certifying physician to document that he or she, or a non-physician practitioner working with the physician, has seen the patient. CMS implemented the face-to-face encounter requirement of the ACA via the Home Health Prospective Payment System (HHPPS) Calendar Year rulemaking. The Final Rule states that documentation of the face-to-face encounter must be present on certifications for patients with starts of care on or after January 1, 2011 .

Office of Inspector General (OIG) work conducted, before the ACA mandate went into effect, found that only 30 percent of beneficiaries had at least one face-to-face visit with the physicians who ordered their home health care. This constitutes new and material evidence that establishes good cause for reopening as required under 42 CFR 405.980(b). Based on this information CMS has directed Strategic to perform postpayment review of Medicare Part A Claims billed for home health services.

As you well know, it is most unlike me to be argumentative but I googled ‘home health referral sources’.  As it turns out, the CDC information from 2010 is in stark contrast to the information provided by the OIG via Strategic Health Solutions.

referral sources

This graph states that providers who only offer home health services have 40 percent of their admissions from a hospital.  It says that 30 percent were from physicians but not that they were the outcome of actual physician visits so lets assume none of them were.  Sadly, the CDC’s 2010 report references 2007 data.

Lets move on to MedPac.  They write reports twice a year for the Congress about how much we are overpaid.  They increase our confusion by writing about how many episodes are preceded by a hospital stay but their data reflects 2010 so that’s a plus.  They say that 27 percent of initial episodes are preceded by a hospital stay and the average length of stay for those patients was 1.4 episodes.  That means that 38 percent of patients come from a hospital.

Neither MedPac or the CDC differentiate between patients  who were in the hospital seen by physicians who did not order their home health and those that did.  If a patient was from out of state, it might be that their personal doctor ordered home health or that a hospitalist saved that special joy for the primary physician.   This is important because it shows how accurate data could potentially be manipulated to paint an inaccurate picture of our industry.

In any event, I can say with confidence that at least 38 percent of patients were seen by a physician because that’s what happens in hospitals.  Doctors come write orders, nurses carry out the orders and the cafeteria always closes five minutes before you can get away to lunch.

So, we have huge discrepancies between the CDC, the OIG/SHS and MedPac.  Who are you going to believe?  My money is on the OIG because the CDC and MedPac do not have the authority to arrest me or monitor my email or phone calls.

So, after that long and rambling trip through the unfamiliar territory of numbers, we are back at the 30 percent mark referenced in the letter reproduced above sent by the OIG/SHS.  That leaves us with some disturbing facts.

We have an entity that looks like a RAC, walks like a RAC and quacks like a RAC but is really a Medicare Supplemental Review Contractor.

The RAC lookalike has noted that in 2010 providers did not adhere to guidance that was effective in 2011.

This non-adherence from 2010 constitutes NEW AND MATERIAL evidence that is being used as grounds to investigate home health care agencies for fraud.

And they will find it.   And it will not in any way, shape or form improve the care that our patients receive.

Note:   Pre-Nursing was the only curriculum that did not require math when I was in college which is why I chose nursing as a career.  Please feel free to correct any mathematical errors – politely, of course.

Nov 14

14 Comments

The 150M Settlement

It doesn’t make me feel good to know that Amedisys has had an exceptionally poor quarter and has tentatively entered into an agreement with the Department of Justice for a 150M settlement. I admit I am a little curious about the reference to The Stark Self-Referral Matter referenced in Amedisys’s press release but not overly disturbed. What disheartens me is that I am no longer surprised by the fact that when I searched the Internet for information, there were hundreds of results that all reported on the stock price.  Nobody stopped to wonder how a 150M dollar settlement would affect the care that Amedisys is supposed to be providing to patients.

Does this mean that I do not agree with the settlement? I don’t know all the details but I think that if the Federal government is going to get between Amedisys and that much cash, a legitimate question arises about their ability to care for patients and compete in an overcrowded market.

Amedisys is clear that in paying 150M to the government that they are not admitting any wrongdoing. I do not believe that they are willingly entering into this agreement because they couldn’t figure out what to do with extra cash. Not admitting wrongdoing is not the same as denying any wrongdoing. If they stayed out of the grey areas, I suspect they would be more than willing to pay a fraction of that to good defense lawyers.

While I don’t know the specifics of the settlement, I do know that it takes a lot of money to care for patients. I may find a bullet in my head in the morning but I strongly believe that if Amedisys is to pay 150M to the feds then Amedisys should no longer be afforded the privilege of billing Medicare. There is no shortage of stellar, high performing agencies who could pick up the slack and most of these smaller players would have never been given another chance by Medicare.

Alternatively, if they have been assessed as compliant and capable of caring for patients then the feds should lessen the penalty to an amount that does not interfere with patient care.

Just sayin……

Oct 8

11 Comments

What Would My Life Be?

 

Dr. Quaid was a phenomenal cardiologist, now retired and indulging in another talent, art.  He has a fondness for John Deere Tractors, a very wry sense of humour and a quiet demeanor.   I haven’t seen him in ages but he used to run and enjoy outdoor adventures and I think he was secretly proud when his daughter was Mickey Mouse at Disney World one summer.  If you live in Baton Rouge, you can see a drawing he did of the graduating class of Episcopal High at Raising Cane’s on South Sherwood.

So, I have an enormous amount of respect for Dr. Quaid and I can honestly say that I like the man.  He is my second favorite cardiologist after Dr. Wall.  Having said that, please take notice that when I described all of his wonderful characteristics, never once did the words, ‘warm’ or ‘fuzzy’ find their way onto your screen.   He is not one of those men that people call a Big Teddy Bear nor is he the go-to guy for small talk or casual conversation.

You need to know this about Dr. Quaid to understand the kind of day I had when I was working in CCU a few years ago.  A patient who happened to be a relative of one of Dr. Quaid’s partners had an urgent need for a pacemaker.  Dr. Quaid drew the short straw and had to install the unit and I was the only nurse with an empty bed.

He was not happy and I was not happy and the entire unit was not real happy but off we went to conquer another case of nagging bradycardia.

With marginal cooperation from the patient, Dr. Quaid began injecting the area with Lidocaine and began in earnest to float the weapon of dysrhythmia destruction down some large vessel towards the heart – I believe they call it a subclavian but then again, I wasn’t the one steering.  As he was doing so, the patient‘expressed some discomfort’ (screamed at Dr. Quaid to stop) and a decision was made to give him more lidocaine.

It was probably one of those cost reducing measures that resulted in the Central Line kit having only syringe in it.  That one, lonely syringe had long been knocked on the floor but I had another syringe Dr. Quaid could use if he did not touch the cap.  I told him this.  “Do NOT touch the cap,” I said loudly and clearly.

He touched the cap which meant I had to tell Dr. Cheerful that he was contaminated.  Worse, there were no size 8 gloves in the cart and he wouldn’t even try on the 7.5’s.

So I went to fetch another pair of  gloves out of the supply room and somehow caught the corner of the sterile field, knocked the clipboard off the sink causing papers to fly everywhere and tripped and fell through the curtain that was affording the patient (but not me) a small measure of dignity.  I got Dr. HugeHands his gloves and then stopped for a brief second to emotionally prepare for my imminent death or worse; that moment when I wished I had assumed room temperature but didn’t.

So, I can’t say I stepped lightly back into the room where  Dr. Quaid was putting my mess in order. I handed him the gloves and waited for that first caustic word but it never came.  Silence.  Utterly loud, screaming silence.

He quietly returned to his task of electrical wiring but I knew he was unhappy.  I’m intuitive that way.   I pretended not to notice and watched the monitor to see when the pacer wire found its way to its final destination.

The silence grew louder until I couldn’t stand it and I blurted out that I had  endured 14 years of ballet lessons in three countries because my Mom thought it would make me more graceful but she was wrong.  I did not tell him about the ballroom dancing taught by nuns, the tennis partners who refuse to play with me unless an ambulance is on standby or the fact that I have been voted most like to die of a closed head injury in yoga during Savasana.  Still not a word from Dr. Quaid.

After three hours or maybe it was only three endlessly long minutes, he stopped in the middle of a tying a suture, made direct and intimidating eye contact with me and said quite simply, “I hate to imagine what your life would have been like without those dance lessons.”

There is a reason why I am telling you this ridiculously long and utterly humiliating account of an incident that happened long ago.

Keep in mind that on more than one occasion, seizure precautions have been implemented as I attempted to dance when I tell you that many of you cannot write for beans.

Remember that I have been described as an arthritic swan by ballet teachers when I point out that some of you cannot string together a grammatically correct sentence to save your life. Its downright sad to see some of you go through your entire vocabulary in one clinical visit note.

That I have twerked by accident during a Waltz should you make you feel better about visit notes that could be used as a poster for an Adult Literacy campaign were it not for the HIPAA Privacy Rule.

The fact is…. some of you simply do not write well and that’s okay.  Apparently, I do not dance very well.  Much to the dismay of others – a whole lot of others – it doesn’t stop me from trying.

If I hurt your feelings and you are ready to quit, don’t.  If you think your computer documentation will solve your problems, get over it.  If you have lived more than three decades and find yourself correcting more than half of your visit notes after review, give up on trying to be a literary presence.  All you really need to do is accurately convey your thoughts on paper and I am going to teach you how.  Remember, Medicare does not pay for grammar and spelling.  There are no Pulitzer prizes for visit note narratives.

Instead of trying harder, working more, adding more drivil to your notes, simply document the following on each and every visit:

  1. A short description of the patient and what they were doing when you got to the home.
  2. A complete assessment including weights.  Note:  in other health care environments, patients with aortic stenosis have very loud heart murmurs and patients with COPD wheeze.  In other words, document your findings – don’t just check the same old boxes you normally check.
  3. A review of all medications against orders.  Document any discrepancies.
  4. Problems assessed on the visit and any events reported since the last visit.
  5. What you did about the problems.

Example:

Patient at table making holiday plans with f’ly member upon arrival.  Med planner reviewed and noted all medications present.  Pill bottles examined and called MD for refills for Metoprolol.  MD office nurse stated meds would be called to Walgreens.  Pt has loud murmur which has been there since admit.  MD verified that pt always has murmur on admission.  Diabetic foot care done by patient while SN watched.  Pt performed foot care with just a little coaching from nurse.  Pts daughter present during visit and she agreed to pick up medications.  Will follow up.

Then write yourself an email or put a note to follow up on your calendar.  Call the daughter who picked up the meds to verify they are in the home and write a case conference that says:  ‘Daughter said she picked up meds from Walgreens.  See visit note of 09/13.’

Compare that to:

Pt was instructed on the significance of attempting to remember if he took medications before taking other meds.

I read that in a chart of a patient with Alzheimer’s Disease.  Medicare paid for a nurse to instruct a patient with Alzheimer’s on the significance of attempting to remember if he took medications before taking other meds.  And you wonder why I am so brutal in my assessment of your documentation.

The truth is that I know you guys.  You work hard, keep patients out of the hospital, make them well and happy and you deserve to be paid – not arrested.  I’ve heard some of the documentation classes.  I’ve read the examples.  Please don’t bore me with those cold, clinical assessments that tell me nothing about the person you are visiting.

Go practice.   Keep it simple.

 

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