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Poor, Black People Have Worse Home Health Care Outcomes


An article came across my desk last week suggesting that Poor and Racial Minorities have Worse Home Health Care Outcomes.  If this surprises you, please stop reading and surrender your nursing license now.

If you read further, the article clarifies the Racial Minorities as Black even though the OASIS data set collects information on American Indians, Alaska Natives, Asians, Hispanic and Latinos, Native Hawaiian or Pacific Islanders as well as white patients.  So essentially, what the article is stating that if you are Black or poor, your health outcomes are worse.

Nurses know that African Americans are predisposed to certain diseases and conditions.  Hypertension and diabetes come to mind immediately. Nearly 42% of Black men and more than 45% of Black women aged 20 and older have high blood pressure.

It is the sequelae of those illnesses that disproportionately affect the black community.  This is where economics comes in and skews the healthcare received by Black people to an unacceptable degree.  Specifically, consider the following statistics:

  • Blacks are up to 2.5 times more likely to suffer a limb amputation and up to 5.6 times more likely to suffer kidney disease than other people with diabetes.
  • Strokes kill 4 times more 35 to 54-year-old black Americans than white Americans. Blacks have nearly twice the first-time stroke risk of whites
  • Cancer treatment is equally successful for all races. Yet Black men have a 40% higher cancer death rate than white men. Black women have a 20% higher cancer death rate than white women.

Additionally,

  • Black Americans are half as likely to get flu and pneumonia vaccinations as white Americans.  See last week’s blog post.

This information is obtained from an article on WebMD

There are so many reasons for these disparities that the study is almost useless to the home health industry.   So maybe the answer is to do what we always done – assess the individual needs of our patients and plan care accordingly.  But sometimes in our effort to be ‘color blind’ factors are overlooked that are closely correlated with being Black and poor in the USA.

About 24 percent of Black people cannot read past a basic level compared to 14 percent White people.  This information is not part of the OASIS dataset and probably shouldn’t be because the time and skills to assess reading ability are not available to us.  There are ways around illiteracy as most nurses know but they take time.  Take your time and be creative.  Send us an account of how your teach patients who cannot read.

Patients younger than 62 who are referred to you may have Medicaid as a primary payor.  In some states, Medicaid provides second rate health care encouraging the use of Emergency Room services when the patient is unable to wait for an appointment set in the distant future.  Medicaid approvals for some medications take time.  We can’t do anything about how the Medicaid system works but we can help the patients navigate the maze.  The truth is that we should be able to treat patients the same regardless of payor source but that ship sailed a long time ago.  If you want to be effective, you must know how the Medicaid system in your state functions.

Poverty and crime have an enduring relationship that isn’t likely to end soon.  Even though you are Wonderwomen and Supermen, you are not able to flash your badge and arrest the bad guys.  Consider the constant stress of living in a home where violent crime is common and how that might affect a patient.  When family members are addicts, patient medications may be diverted leaving a patient in pain unless they want to report a loved one to the police.  I have seen doors with multiple locks leaving me to wonder if there is an escape route in the event of a fire.

In rural areas, crime may not be a problem but the expense of getting to a physician’s office may be out of reach.   Family members may be willing to drive the patient but if they work, they might lose an entire day’s wages.  In these cases, it is possible that truly diligent assessments along with detailed reports to the physician may occasionally eliminate the need for an office visit.

Cheap food is frequently not on cardiac or diabetic diets.  Plus it adds body weight complicating pretty much every disease or condition.  The fact is that poor people eat cheap food and patients who cannot read are unable to follow that food list you gave them, anyway.

As much as we would like to, we cannot teach the world to read, fix Medicaid or reduce crime.  Driving patients to the physician’s office is impractical and basically a bad idea for reasons that would fill another blog post.  You can’t even plant a garden in their backyard to provide vegetables.

We have to look for allies.  Every agency should have a list of community services that can assist us in improving our patient’s’ chances of becoming a little more independent.   It should be reviewed regularly and distributed to all nurses.  Meals on Wheels isn’t the only service available.

We also need to realize that while outcomes are important, there are some things we cannot control.  When someone has untreated hypertension resulting in a stroke prior to admission, it is unreasonable to expect the same good outcomes that result when a patient is referred after being diagnosed with hypertension before a stroke occurs.   That doesn’t mean that we shouldn’t try our best.

The bitter pill to swallow is that our best may not be good enough.  But, it could be better.   Your personal best may be to spend an extra ten minutes with a patient so your functionally illiterate patient can understand the education you provided.  An agency may adopt a policy where breaking even financially on poor and Black patients is acceptable and schedule a few more visits.  Case managers could supplement visits with regular phone calls.  Safety for nurses and patients may be enhanced by an inservice from local law enforcement.

The value of a life is constant throughout races and economic status.  As Malcomb Forbes once said, “You can easily judge the character of a man by how he treats those who can do nothing for him.”  But you may be surprised.  The people who appear to be able to do nothing for you often do the most.

NOTE:  This is an article about African Americans.  I have used the term ‘Black’ because that is what was found in the literature and it is easier to type.  No disrespect is intended.


Above is a very basic quiz on home health documentation.  It focuses on the type of errors that will result in claims being denied.  Is there a greater insult to a nurse than telling him or her that they do not deserve to be paid after going above and beyond to care for their patients?

Don’t let this happen to you.  Click the ‘Start Quiz’ link and find out how well your documentation measures up.  And call us if your agency might benefit from training from Haydel Consulting Services.

 

Tuesday Musings


As promised, here are the answers to Monday’s quiz.  See the previous post below this one if you missed out on the quiz.  In fact, stop reading now and answer the quiz if you haven’t already done so.

The first response was that therapy should be provided under the management of a physical therapist.  This makes perfect sense to me.  And in agencies large enough to have a separate therapy department, I highly recommend a director of therapy.  However, it is clearly stated in the Conditions of Participation for Home Health and most state minimum standards that all care in an agency is provided under the direction of the Director of Nurses.  This is very challenging for many nurses, including myself.  How do we manage therapy if we don’t know exactly what it is that they do?  Looking at the larger picture, is it so much different than a CEO of a major airline managing pilots and mechanics when he or she has never flown or repaired a plane?  In order to manage therapy as nurses, we must cultivate trusted sources and work with therapists who do not feel threatened when we question their work.  We learn a lot this way!

The next response has to do with visit frequencies.  Certainly therapy plans of care that include 7 or 14 visits are financially lucrative and there is nothing at all wrong with keeping payment criteria in mind when determining frequencies.  In fact, it is important to be aware of these numbers in an agency that wants to do well financially.  However, the ultimate frequency that the patient receives should be the one that best reflects the patient needs.  Always.  If a patient needs 13 visits, then that’s what the patient should receive. (However, show me a patient who requires 13 PT visits and I bet I can find a need for a few OT visits in the clinical documentation!)

The third answer involving wound care was correct.  It is within the scope of practice for physical therapists to perform wound care.  In fact, physical therapists can do certain things that nurses cannot such as sharps debridement in most states.  This can work to an agency’s advantage two ways.  First in wound care patients receiving physical therapy, duplicate visits can be eliminated by having the therapist assess and perform wound care on days when PT is ordered.  Secondly, consider a PT wound care program if you are not suffering from a lack of physical therapists.  Choose one or two interested therapists and invest in advanced wound care training for them.   If your agency decides to take advantage of either of these advantages of therapists performing wound care, be sure that you specify that physical therapy should be doing wound care on the plan of care.

The last answer about OASIS was also incorrect.  Many agencies choose to have the nursing staff perform all OASIS assessments.  This may be a sound strategy especially when physical therapists are in short supply.  However, in an agency where a large number of patients are admitted for physical therapy only, consider training the therapists to perform the OASIS assessment.  This eliminates the need for using a nurse to do an assessment and then write a care plan based upon the PT’s assessment.

If you have any questions about the answers to yesterday’s quiz, please post them below in the ‘responses’ box or email us at haydelconsulting@bellsouth.com.

Monday Morning Quiz


We are starting the week off with a quiz to get your brain cells firing.  There’s only a couple of days that most of us have to think about home health this week and then it’s all about pumpkin pie recipes and football.  I would gingerly remind those of us on call this holiday weekend that patients are sick every hour of every day and we should be thankful that we are afforded the opportunity in life to care for patients in need even when it is most inconvenient. If that thought doesn’t lighten your load, remember that if you are working Thanksgiving Day, you are likely off on Christmas!

Our quiz today is about home health physical therapy.  Answers will be posted tomorrow.  Many of our clients are continuing to struggle with therapy management and so for the next several weeks, we will try to devote at least one column a week to home health physical therapy.  Any questions, comments or suggestions about therapy should be left below in the ‘responses’ box or emailed to Haydelconsulting@bellsouth.net.

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