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by Julianne Haydel

So Long, Therapists


For years we have been reading clinical records from many agencies. Therapy has been overutilized in some and underutilized in others but mostly, therapy use has been responsible.

Medpac and others advising the congress don’t believe that. They have been advising Medicare to do away with payment per visit for therapy for years.

These are mostly people who have never been in a home health agency. They are looking at claims data and OASIS. Their interest is in reducing healthcare costs.

Welcome to PDGM where therapy no longer results in an add-on payment. Medicare is expecting that therapy will be included in the payment rate for diagnoses and functional scores that were typically associated with therapy in PPS.

For example, we made up a patient falling into the rehab group (an ortho diagnosis) with a comorbidity of atrial fib which is a med management cardiac group. The actual diagnosis was a recurrent dislocated hip. Our made-up patient was given scores in the functional domain as follows:

Hospitalization: History of falls, five or more meds, two or more hospitalizations, reports exhaustion.

Grooming: Someone must assist

Dressing: Someone must assist dressing upper and lower body

Bathing: Unable to bathe and requires the assistance of another person to bathe

Toilet Transferring: Can use a bedside commode

Transferring: Able to bear weight but someone must transfer patient

Ambulation: Able to walk with the supervision of another person at all times

Our patient came from a hospital and this was the first admission (institutional; early)

Payment, per the CMS grouper, came to just under $2,700.00 for 30 days with a LUPA threshold of 6.

There are some other considerations but hopefully, this is close enough to convince you that you can afford therapy. In fact, because the patient required no surgery and was likely already knowledgeable about anticoagulation, it would be difficult to justify six nursing visits in the first 30 days.

This exercise in payment is probably pointless for the nurses and therapists read blogs about home health. It is rare for agencies to allow payment to determine clinical care. To be certain, we must all work within the confines of the payment system and it can be done. You will lose a few dollars on some patients and other patients will be more profitable.

Heaven help the patients of those agencies who are motivated solely by payment when a greed ridden owner figures out that payment will not change if they withhold therapy from their patients who need it. If there are enough of those agencies, Medicare will notice that therapy has been reduced and all agencies will suffer another payment reduction. Hopefully, Medicare will be analyzing claims data because outcomes will be slow to reflect changes.

Agencies that have no plans to reduce needed therapy or skimp on care in any way should include advice to referral sources that therapy orders need to be reviewed. When they see no therapy or very little therapy for patients that would benefit, they need to take time out of their day and call or merely alter the care plan. If this becomes a pattern with an agency, the referral source should look for another agency.

We can’t do anything about how Medicare payment policies but we can give our patients everything that they need. There is always going to be a way to game the system but Medicare will catch on and until then, you fight as hard as you can on the front lines for your patients. Like you always do.

Call if you have questions. If you have any sage advice for us as your first claims are going out, we want to know. Leave your comments or email us. And remember, we are always willing and able to help you with your OASIS review and coding so that you get the maximum ethical payment.

by Julianne Haydel

PDGM for Nurses


This brief overview is directed specifically to nurses and therapists who will be completing the OASIS assessments that will determine payment. This is not a complete guide to PDGM but it is important for the field clinicians.

You work hard. Get paid.

by Julianne Haydel

A PDGM Primer


It’s almost time for PDGM, the payment system that could dampen our holiday spirits if agencies are not ready. As you can see by the chart below, provided by our friends at CMS, the HIPPS code, which determines payment, will be calculated a little differently than the current PPS HIPPS code.

Position 1 will refer to a new 30 day billing cycle and only the first 30 day period of care will be considered ‘Early’.  Bring your billers Starbucks or Redbull.  They will need it as twice as many claims will be dropped.  And yet, OASIS will still be collected on the same 60 day cycle.

Look at next column. There are 12 different groups into which patients will fall according to their diagnosis codes. Most agencies have certified coders (presumably us) and the assessing clinician’s job is to provide accurate assessment information to assist The Coders in finding the correct codes and sequence. Many codes that are currently used will not be accepted as primary in PDGM and The Coders will be searching for clues to refine the diagnosis codes.

The source of the episode is not very flexible but agencies can change marketing strategies to try to increase the number of patients admitted post hospital. Understand that refusing community referrals that meet your admission criteria policy to improve your ‘numbers’ is highly unethical and possibly illegal. But, if you have a very high percentage of community admissions, there is nothing wrong with increasing marketing efforts to surgeons and other physicians who typically admit patients directly after a hospitalization.

elderly-folksThe admitting clinician’s largest contribution to payment is the functional domain which has been chronically under assessed and given the least attention of all payment elements. Many agencies will be leaving money on the table and risking denials for homebound status if nurses and therapists don’t know how to respond to the questions make up the functional status. There are eight OASIS questions used to in the PDGM calculations and seven of them are the functional domain questions.

The first place to start is teaching and reteaching the Conventions for completing OASIS. The can be found in Chapter 1 of the manual. They haven’t changed since the advent of OASIS but as new clinicians rotate in and out, they are often overlooked in orientation. The ones that are misunderstood are sandwiched between statements of common sense. Here are two that are frequently misunderstood (without wonder).

  1. Report what is true on the day of assessment unless a different time period has been indicated in the item or related guidance. Day of assessment is defined as the 24 hours immediately preceding the home visit and the time spent by the clinician in the home.
  2. If the patient’s ability or status varies on the day of the assessment, report the patient’s “usual status” or what is true greater than 50% of the assessment time frame, unless the item specifies differently.

These two conventions could mean that some of your patients who had a procedure the day before admission are being underscored.  Misunderstanding them  could also cause a nurse to underscore a patient if they simply record what is true at the time of the visit. (Read about a real life example from 2009 here.) Sundowning generally occurs after the nurse’s visit. Add a sleeping pill at ten PM and it could be true that the patient wasn’t safe to get to the restroom independently for over 12 hours of any given day. Agencies can improve OASIS scoring and ethically increase payment by understanding these two conventions.

Here are two more.

  1. Understand the definitions of words as used in the OASIS.
  2. When an OASIS item refers to assistance, this means assistance from another person. Assistance is not limited to physical contact and can include necessary verbal cues and/or supervision.

The definitions of words as used in OASIS often varies from normal everyday use. This is why seemingly intelligent employees sometimes answer OASIS questions incorrectly. Consider OASIS question m2020 that investigates the patient’s ability to take all oral medications but when you read the OASIS manual it instructs us to consider the medication for which the most assistance is needed when selecting a response.  (Why the bold, italicized font if the definition of ‘all’ wasn’t ‘all’)

If a family member must constantly remind your patient to use a cane, that is considered assistance. If someone must remind them to eat, they need assistance.

This information is from the official OASIS Guidance manual. It is not an invitation to upcode. Rather, it is a warning to not leave money on the table. Don’t wait until PDGM to teach and reteach these conventions. Start checking admission paperwork now and educating the nurses and therapists doing your admissions when you see contradictions between the chart and the OASIS. Good agencies work hard to provide care to patients and deserve to be paid. We have friends and colleagues working in the field and we see how tired they are at the end of the day.

If you have any questions, do not hesitate to contact us. We are always available to check your OASIS and ICD-10 coding but for now, pull ten charts and see if the functional domain questions are answered in accordance with these conventions.

Don’t worry.  We’re making this adventure with you and will post more information next week.

by Julianne Haydel

Predictive Analytics


I just saw an advertisement for a company offering predictive analytics so that within minutes after the clinician inputs data, predictions are made. It even tells you how many visits will result in a good outcome and what kind of visits those are. There’s another tech company that guides you to better allocate your resources (you are the resource, by the way).

Although I love computers, I wonder if we are trying too hard to substitute computer data for critical thinking. Using computer predictions to determine how much care should be delivered has too many opportunities to fail, and failure in nursing harms patients.

The algorithms in this and other programs are based on thousands of patient episodes. In theory this is good. Validation is achieved by the repetition of results across many occurences. TUG tests and PHQ depression assessments are validated but those results are not influenced to any great degree by data that we are unable to measure.

So, agency owners who are interested in these data crunching, predictive programs might want to ask what information goes into making these predictions and what variables can influence the data. OASIS and basic assessment data is readily available but OASIS does not ask about income or education level; both of which influence a patient’s response to care provided. Typical assessment data does not provide insight into family dynamics or how far it is to the nearest grocery store, hospital or their MD office.

If nurses surrender their own critical thinking to these programs, they are primed to violate the most fundamental of nursing standards by not individualizing care for the patient. Only the assessing clinician can do that. If non-clinical managers use these programs to determine the value of a nurse, he or she may end up on the radar simply for providing the patient what is needed.

I have never seen a computer program brought before the board of nursing or any of the therapy boards. If the computer advised the nurse to insert a knife into the eye of the patient, the computer would not be held accountable for the resulting loss of vision. The nurse is and always will be ultimately responsible for the nursing care rendered to the patient.

The legal implications are enough to make me glad I am not a lawyer and cannot give legal advice. That’s not to say you won’t wish you had called a lawyer before you allowed a computer to make clinical decisions for you.

I am an information junkie. If I had access to one of these programs, I would play with it the way Sheldon and Leonard played Halo on Wednesday nights. But I don’t think that is how this predictive technology will be used. My fear is that clinicians will be judged on how many visits they provide and whether the number falls within the computer generated parameters. I am afraid that careplans will be altered to accommodate an algorithm, and the patient will receive care they do not need or not receive care they do need.

There are no recipes for patient care – add five visits and a teaching guide for diabetes; stir well and season to taste with footcare. The best software helps clinicians care for patients. A good system frees up time by handling non-clinical tasks and minimizes the work of complete and accurate documentation . (No routine visit nursing note should require 20+ pages when printed.) Documentation in the home during a visit is ideal but not if it puts the computer between the patient and the clinician. Making information available when needed is much different than a Where’s Waldo game to locate vital signs in a sea of useless information.

Most State Boards of Nursing have a statement similar to the below taken from the Louisiana State Practice Act:

The standards are based on the premise that the registered nurse is responsible for and accountable to the individual for the quality of nursing care he or she receives. Documentation must reflect the quality of care.

If you are unable to find a similar statement in your state’s practice act, look for one that says:

Computer directed nursing is acceptable should the nurse not feel up to thinking critically.

You probably won’t find anything like that. Registered Nurses are able to delegate tasks but never responsibility.

If you have a different opinion, we’d like to hear it. Please email or leave a comment. And remember, we are information junkies and do not want to go into flagrant withdrawals but we also think you can do a better job of caring for patients than any software, anywhere, anytime.

And we can help. We have coding and OASIS certified nurses ready to review your admissions and give you the information you need to craft a care plan.

by Julianne Haydel

Opioid Use in the Elderly


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A few years ago, I was reviewing the clinical record of a patient who had just been discharged from the hospital with a severe GI bleed. While he was hospitalized, a drug screen was run and it was determined that he had no opioids in his system despite the fact that he had Lortab ordered three or four times a day. Going back further, I read that while his wife was present during visits, she was often ‘napping’. I do not know how the physician knew to order the drug screen but it’s not a long leap to figure out why Adult Protective Services were called. As it was discovered, the patient’s wife was substituting two aspirin for the Lortab doses; hence the bleed.

Fast forward to a couple of months ago when I read a chart of a man who had chronic back pain. He had been taking oxycodone for years and had recently underwent surgery which mostly corrected the cause of his pain. He then fell and was admitted for pneumonia. The admitting physician said the patient asked for much more than his prescribed dose of pain medication. When he received it, he was somnolent and showed other signs of overdose.

Then there was a patient whose chart indicated that she had very severe 10/10 pain on each visit. The physician was not called. I called the agency on this during a meeting as multiple clinicians had seen the patient. They told me that what I didn’t see was the five o’clock news when the patient was arrested for selling her prescription medication.

Here are some facts.

  • Pain affects approximately 100 million American adults each year, resulting in a national cost of $635 billion annually in medical treatment and loss of productivity.
  • Medicare beneficiaries (aged and disabled) have among the highest and fastest-growing rates of diagnosed opioid use disorder at more than 6 of every 1,000 beneficiaries (CMS, January 2017).
  • In 2011, on an average day, 80 adults aged 65 and older visited the emergency department for problems with narcotic pain relievers and seven older adults’ visits (on an average day) involved heroin (Mattson et al., 2017)

Obviously, there is more information and statistics about Opioid use in the elderly. Half of the internet could be filled with the complex reasons of how the epidemic began but that is hardly useful information. The most useful intervention that a visiting clinician can employ is common sense which is exceedingly uncommon in healthcare. Consider the following:

  1. Blind adherence to CDC guidelines is causing some patients who have been on large doses of narcotics for years to have their doses abruptly dropped by a significant level. This Huffington Post Story tells the story of Jay Lawrence who had his pain medication reduced by 25%. Shortly before the next pain management visit, when he expected that his dosage would be reduced again, he committed suicide. If a visiting nurse or therapist had been in the home, they could have tried to intervene by documenting the patient’s history including prior and current abilities. Although awkward, the CDC guidelines should have been reviewed with the physician as he appeared to be following guidelines for patients new to narcotic pain relievers.
  2. Disabuse yourself of the notion that narcotics given for legitimate pain do not cause addiction. Many of you will be insulted by this tidbit of advice but this information was shared with healthcare providers for years by pharmaceutical sales people. In fact, there is no ICD-10 code for addiction – only for dependence which occurs after taking the medication for a prolonged period of time regardless of the reason.
  3. Do not hesitate to code an F11 code if you have physician documentation.
    Assess the patient completely for pain remembering that assessment is more than interview. For years, we were told by very respectable organizations that the patient’s pain was what the patient said it was. That’s not always true. A full assessment includes observation of the patient’s ability to participate in daily activities, assessing sleep patterns, appetite and nonverbal behaviors such as grimacing, inability to focus on what you are saying and guarding the area the area where the pain is. Ask family members when present during assessments if the patient shows signs of pain during the evening or in the mornings when getting out of bed.
  4. The blind adherence to CDC guidelines has physicians focusing on the amount of opioids ordered but they seem to be oblivious to the recommendation that they find treatment and/or support for patients who may have a serious problem. The physician is more likely to refer a patient for help if you have suggestions handy. Waiting for an order takes much longer than asking for an order for a referral to specific providers.
  5. If your patient has been abruptly cut off or has had a sharp reduction in pain medication, be aware that suicides increase dramatically after the cessation of opioids. Depression is part of the withdrawal process and can be intolerable for patients who have an existing diagnosis of depression.
  6. Include both long term and short term effects of opioid pain relief. This is especially valuable for patients who do not take opioids on a regular basis but are undergoing a procedure that will leave them with pain. Help them set realistic pain goals. Teach your patient that pain medications should reduce the pain to where it is tolerable but can cause falls, confusion and impaired judgement. Long term, speak to the idea of tolerance to the medication and dependence. Reassure them that problems do not occur if they take pain meds infrequently for a short period of time and return to tylenol or NSAIDs as soon as their physician allows. Teach caregivers to wait until the patient asks for the medication instead of giving it routinely.
  7. Visiting clinicians probably see diversion more than most other healthcare providers. If there is any suspicion of diversion, ask the pharmacy to dispense only a week at a time so that missing medications will become obvious sooner if that is allowed in your state. Alternatively, ask for two pill bottles and keep only seven days worth and (with the patient’s or trusted caregiver’s knowledge) hide the remainder. If you know with reasonable certainty that medications are being taken from a patient, call elderly protective services and allow them to investigate. If there is doubt about why pills are missing, call in the social worker.

The extremists on either side of the opioid crisis are costing money and in some cases, lives. Complications from opioid use have resulted in opportunities to create new laxatives specific to Opioid induced constipation that are priced upwards of 350.00 per month. The sexual performance pharmaceuticals are also benefiting as patients suffering Opioid induced sexual dysfunction need a little boost. Falls in the elderly taking opioids are common and should a hip be broken, there is a 25 percent chance that they will not be alive in six months.

And yet, there is no feeling more powerful than shooting some morphine into the veins of a patient suffering from kidney stones. Hospice patients have a better quality of life with opioids and they are very useful for fracture and burn patients. Make no mistake. Opioids have their place as do antihypertensives, diabetic medications, etc. but they need to stay in their place. Patients should be cautioned about taking opioids for chronic pain unless all other avenues of pain relief have been explored and nurses and therapists need to be honest and unreserved in their teaching of medication safety.