Monday, September 29, 2008

Insurance Guru: Sending Hospice Visit Data to the Big Bad Wolf (Part 1)

While I was doing some research on Hospice budget cuts and funding for my previous post, I ran across all sorts of FAQ's on the Centers for Medicare and Medicaid Services (CMS) website regarding new Hospice reporting rules. The reason given for this data mining effort?...

"The Medicare hospice benefit was implemented in 1983. Since that time, the benefit has grown considerably. Unlike other payment systems, hospice providers have had to provide minimal information on the hospice claim. The Office of the Inspector General (OIG), the General Accounting Office (GAO) and the Medicare Payment Advisory Commission (MedPAC) all recommended that CMS collect more comprehensive data in order to better evaluate trens in utilization of the Medicare hospice benefit. This additional information will help to provide a better understanding of the types and frequency of hospice services provided during a day of hospice care."

I've worked with provider contracts and their coding for years and in that time, four simple codes have been used for all Hospice billings:

651 - Routine Home Care
652 - Continuous Home Care
655 - Inpatient Respite Care
656 - General Inpatient Care

Remember, Medicare develops the coding and updates happen every year. If they've been getting minimal coding, it's because they've provided minimal coding choices.

Medicare now requires Hospices to provide additional coding to indicate where the patient is being cared for (in the home, in a SNF, etc.) as well as the visits the patients is receiving. Interestingly, they are only requesting data on physicians, nurses, home health aides and social workers. Why? And the answer is:

"We selected the physician, nurse, home health aide and social worker because we have existing revenue codes available to capture this information on the claims. We recognize that this does not represent all care or the items provided under the hospice benefit."

Wait - "we recognize that this does not represent all care or the items provided under the hospice benefit"? Is this some weird alternative universe where it only counts if you can give it a code? Oh yeah... it's Medicare, so it is an alternative universe.

Thursday, September 25, 2008

Articles of Interest: The Sandwich Generation

The "Sandwich Generation"

Those of us that are caring for elderly, ill or dying parents and also have children to tend to in the home are often labeled as members of the "Sandwich Generation". It's certainly not a new concept... humans have likely been "sandwiched" between caring for their children and ailing parents for countless generations. However, nowadays, many members of a single family may be scattered throughout the world... making information gathering, decision-making and "hands on" care more complicated than ever.

Over eight years ago, I became a member of the Sandwich Generation. My parents moved into my home to live with me and my twelve year old son. My father's dementia was severe and my mother could barely walk. After six months, the stresses of care giving, full time work, "making ends meet" and seeing that my son received the attention that he deserved took its toll. It truly was one of the most stressful, anxiety-filled and guilt-ridden times in my life.

It took a long time and a lot of hard work, but I finally found solutions in the form of a high, quality group home and later, an excellent long-term care facility. My parents have since passed on, but I have no doubt that they received excellent care in safe and attentive settings. It was not the ideal solution. I truly wished that they could have stayed with me until the end, but it was, indeed, the wise thing to do.

Internet access to resources, information and discussion forums was mighty thin when my parents were living with me. Google was less than two years old at the time. Fortunately, there is now a lot of information on the internet for those who are "sandwiched" and those who wonder if that time is looming on the horizon.

Finding local, community services
Department of Health and Human Resources -- "Eldercare Locator"

Solid, practical advice from CNN
"Sandwich Generation: Survive the Mid-Life Tug of War"

"The 10 Signs Your Elderly Parent Needs Help"

A more humorous slant from AGIS
"Top Ten Signs You Are a Sandwich Caregiver"

Tuesday, September 23, 2008

Ghost Tour

It's been a while since we've been on a ghost tour...

Today, I proudly present this extraordinary footage. It was submitted by a man who is certain that he is being visited by the spirit of his dead, drunken brother.

Hold onto your hats... this is a shocker!

Monday, September 22, 2008

Insurance Guru: Medicare Cuts and Hospice

It is my pleasure to introduce to you my good friend and shiny, new guest blogger, Insurance Guru. Yep, she's smart AND she's got opinions. Just remember... I don't know ANYTHING about insurance or Medicare so please send your questions, etc. to her email on the link below. Any comments on this post will be addressed by Insurance Guru.

My favorite hospice nurse blogger, Dethmama, asked me a question the other day - will the cuts in Medicare hospice reimbursement affect a hospice running under a "managed care umbrella"? How will the "mom and pop" hospices fare? She had obviously been reading the
Hospice Blog.

While this isn't your normal topic of conversation over a couple of drinks, I do have over 20 years of experience in the health insurance industry and currently work for one of the largest in the nation. I have seen, firsthand, what happens when Medicare (the government - insert "Theme from Jaws" here) has found a target to save some bucks.

So Medicare has announced that, in a nutshell, they are not going to increase reimbursement rates to hospices for the next three years and thereafter, look to apply a 0.65% reduction in reimbursement. Medicare plans to save 2.2 billion dollars over the next 5 years with this plan.

Where does that leave a "managed care" hospice? Let me first try and explain what a Managed Care Hospice is...

Most of us with insurance fall into some type of "managed care" arrangement. We have a primary care physician and we pick specialists and emergency rooms from the insurance company's list of providers. This is due to the insurance company having a contracted relationship with these providers and it saves all of us money. A "managed care" hospice will also have these contractual relationships with pharmacies, medical equipment companies and any other providers that it does not employ directly. "Mom and Pop" hospices also have contracts with many of the same providers. However, they do not have the same discounts or control. A hospice under the "managed care umbrella" will use these providers to service thousands of their patients and all the other membership under the "managed care arm", so providers are very anxious to do business with them. In many cases, the managed care hospice can insist on service guarantees and annual increase limits to be included in their contracts.

In the short term, this will help a Managed Care Hospice compete in the marketplace and doom the "Mom and Pop" hospices that are already operating at close to a break-even level. Here comes the "but"... Hospices get 70-80% of their budget from Medicare. When the bulk of your revenue stream is going to be stagnant for the next three years, but all your costs are rising, a contract with Walgreen's isn't going to help you. The options are:
  • Raise your rates for the private pay and insurance companies.
  • Load up your nurses with more patients.
  • Decrease services (chaplains, nutritionists, etc.).
  • No more indigent/poor care.
  • Close your hospice and overwhelm the others.
Personally, I hate, HATE all of these options. To me, hospice is the the last bastion of selfless, medical care. Hospice team members help in the small, tidy ways that matter the most to the dying and their caregivers... A calm, knowledgeable voice at 3 AM or a nurse that becomes friends with the family... A social worker to find resources and help with the crazy paperwork... A clergy person of your "flavor" and a physician to monitor your care. AND all of these people come to YOU! Unless the court case and recently introduced bill in Congress turn back Medicare's Evil Eye on reimbursement, hospice will have to become a "big business". Such a pity... we know how those all turn out.

Email Insurance Guru

Friday, September 19, 2008

Shock and Shame

1300 hrs -- I've stopped by one of our inpatient units to see how our patients are doing. The charge nurse, Charlotte, stops me before I begin to make rounds:

"The family in 413 has gone nuts," she says. "We've all tried to calm them down, but nothing's workin'. At least now they're stayin' in the room instead of shriekin' up 'n down the halls and makin' all the other families upset."

"Great," I mutter. "When did Mrs. P. die?"

"Oh, she's not dead, yet... awful close, though," Charlotte replies.The charge nurse then informs me that the "noisy crew" consists of two, middle-aged daughters, one teen-aged girl and an infant.

It's become clear that Charlotte and her staff have "given up" on this group. The usual form of emotional support offered by hospice staff is lost on this family. As long as the family remains exiled in room 413, the nurses, patients and families can get through their day in peace.

I take a deep breath... it's time to introduce myself to Mrs P's family. I quietly open the door, enter the small vestibule and peer around the corner to get a view of the room and its inhabitants.

"Look at the baby, look at the baby, look at the baby..." , the women chant excitedly.

One of the daughters is in bed with the patient. She has straddled Mrs. P. between her legs and propped her up into a sitting position. She is also forcing the nearly dead woman's eyes open with her fingers. Daughter "number two" is dangling the infant directly in front of the unresponsive patient.

"Look at the baby, look at the baby, look at the baby...", the chant is rapid-fire and unending. A short gasp escapes from me and I immediately bolt from the room.

I have counseled many families on the importance of maintaining a calm energy around their dying loved ones. Scream and howl all you want out in the backyard... just don't bring it to the bedside. A "peaceful" death... right? Isn't that what we're shooting for?

Is the family dysfunctional? Are there cultural differences at play that I haven't been made aware of? I don't know, but the scene in room 413 has shocked me and I feel ashamed. Shame on me for being both shocked and incapable of going back into the room.

Humbled, I walk back to the nurse's station and sit silently next to Charge Nurse Charlotte. I don't even get a chance to warm up the chair's seat cushion and...

"SHE'S DEAD! SHE'S DEAD!", screams the teenager as she runs through the hallway. "SHE'S DEAD... SHE'S DEAD!"

"Hoo boy", I say. "I guess that means --"

"Yup...", interrupts Charlotte. "She's dead".

Wednesday, September 17, 2008

"Bullying in Nursing"... a Reader's Response

Buck Bannister read my post on 9/15/08 about the Sentinel Event Alert issued by the Joint Commission. His post, titled "Bullying in Nursing", is a beautifully written piece about his "bulllying" experiences as both a surgical technician and as a transplant patient. His experiences were nothing short of horrifying.

Buck, a relative newcomer to Tucson, Arizona, is a busy blogger with two sites,
Southeast to Southwest and Buck's Ghosts and Hauntings. He is also a member of Sonoran Paranormal Investigations, Inc.

Tuesday, September 16, 2008

I'm a Little Verklempt

I deeply appreciate Hospice Guy at Hospice Blog and Dr. Christian Sinclair of Pallimed for so kindly mentioning this blog on their sites. As Dr. Sinclair mentioned,in his post, "... we're starting to get a good little community here". Yes, I think you're right, Dr. S., but it also means a lot to feel welcome in the "neighborhood". I thank you both for that.

Monday, September 15, 2008

Articles of Interest

In July, of this year, the Joint Commission issued a Sentinel Event Alert that addresses "intimidating and disruptive behaviors" in the health care workplace. Wow! This is a biggie... and I'm not being sarcastic.

Many clinical settings are rife with abuse, intimidation and bullying. Trust me on this one... I spent many years working in a large hospital. During that period, I witnessed a lot of this and spent my share of time on the receiving end of it. To make matters even worse, many workplaces do nothing to encourage the reporting of such behaviors. Don't get me wrong; you can report it. It's just that nothing will be done to correct the situation. It's all too often a "just shut up and take it" kind of attitude.

Medscape Nurses blog submitted a short post on the Sentinel Event Alert earlier this month. I really want you to take a look at the comments. This subject will, no doubt, inspire a lot of passion in the coming months or even years.

This next article also comes from
Medscape Nurses titled, "Who Tells a Patient's Family That Their Loved One is Dying?". While this used to be a bone of contention when I worked in the ICU, I had no idea that this issue would follow me into the area of hospice. Imagine going to the hospital, in order to do a hospice consult with a family, only to find out that no one has told them that their loved one is dying. Being chased out of the room by a mob with torches and pitchforks is just downright... awkward.

Friday, September 12, 2008

Wednesday, September 10, 2008

Fun-filled Funereal Facts

Death Rattle

The death rattle is a very common occurrence among the dying. It is a noisy gurgling sound that can be heard with the pt's breathing. The cause is fairly simple... As the dying process progresses, we lose our ability to swallow and cough. Because of this, oral secretions accumulate far back in the throat. With every breath the dying patient takes, air passes through or around these secretions and creates the rattling sound.There is no evidence, at all, that the rattle interferes with the patient's comfort. However, that cannot be said of the caregivers hearing the death rattle for the first time.

I've received many phone calls from caregivers that are obviously unaware of this common sign of impending death. They almost always tell me that the patient is "choking" or "drowning". I advise the caller on the use of atropine drops, under the tongue, to help dry up secretions and will also recommend repositioning the patient on their side. This is always followed by a healthy dose of emotional support and a review of the dying process. Caregivers will often ask about suctioning the patient. Removal of these secretions would require very invasive, deep suctioning and is rarely accepted in the hospice field.

The importance of educating caregivers about the dying process cannot be stressed enough. The booklets and pamphlets that hospices give their clients are excellent resources, but I suspect that they are often put aside and forgotten. Nothing can replace the information and continuous reinforcement that can be given by the visiting hospice nurse. Of course, not every caregiver is receptive to this information at first, but the education process needs to begin as soon as possible. The more that caregivers know about the dying process, the fewer "shocks" and "frights" they will have as they take this journey with their loved one.

Monday, September 8, 2008

An Engineer's Guide to Cats

My son brought this video to my attention and I loved it. He's in college studying to be an engineer. This is a point of great pride for me and has also quashed any dreams I had for an early retirement. (sigh...)  Anyway, please enjoy...

Saturday, September 6, 2008

Articles of Interest

Unbeknownst to me, there remains a degree of controversy regarding organ donation after cardiac death (DCD). Much of this controversy seems to hinge on the concept of "irreversible" cardiac death and even seems to bring into question how death is determined. Dr. Drew Rosielle, of has an excellent post regarding this topic.

Staying on the same subject, please check out
Dr. Maurice Bernstein's "Bioethics Discussion Blog". He discusses the "Dead Donor Rule" and accepted criteria for determining death. Don't skip the comments on his post... good stuff!

Hopefully, you've got a little extra time to devote to the New England Journal of Medicine's video roundtable discussion,
"Organ Donation After Cardiac Death". The panel really gets to the crux of the matter in a straight forward and easily understandable way.

On a different note, Dr. Christian Sinclair of has posted an article titled "Medications and Driving - Informed Consent?". It's a doozie...
you've got to give this a look!

Last, but definitely not least, Hospice Guy at
Hospice Blog has a great post that links to a blog where a hospice nurse writes stories about her adventures. Hey wait... that's ME!! THANKS, HOSPICE GUY!!!

Thursday, September 4, 2008

Stabbity-Stab The Hospice Nurse

0050 hrs.-- The home is a split-level. I haven't been in one of these in many years. I thought homes like this were so cool when I was a kid. Little kids seem to love steps and stairways. Now, as a middle-aged woman, I have an aversion to them. The idea of lugging the vacuum cleaner, baskets of laundry and grocercies up and down... it's tiresome to me and too filled with "broken hip potential". 

Taking several steps down, I find myself in a small family room with a kitchen off to the side. The body of the deceased, Mrs. L., is in a hospital bed in what used to be the dining area. The dinette set is probably gathering dust in the garage. Families don't just devote massive amounts of time and physical labor to the dying. They also sacrifice square footage.

I make an official pronouncement of death and sit beside Mrs. L's three adult daughters. The patient's son, John, remains standing in the unlit kitchen. The daughters and I engage in the usual small talk as we wait for the funeral home to arrive. 

"Do people sometimes take it out on you when someone dies?", asks John.

"Well, yes," I reply. "But it doesn't happen very much. Most families are very nice."

Zip... click! John has pulled out a switchblade. I see the glint of a four inch blade reflecting from within the shadows of the kitchen.

"Would anyone here like to take a few stabs at her?", asks John, looking at his sisters. 

I quickly glance at the sisters. They sit motionless; their faces without expression. I determine that they're not interested in taking John up on his offer to stab the hospice nurse. Somewhat assured, I turn sharply to my left and stare at John with the coldest, dead eyes that I can muster. It's time to size up the situation.

John is thin and no taller than I am. He's going to have to either make a heroic leap over his mother's death bed or an awkward run around it in order to get to me. I have no weapons, but I'm more than willing to sacrifice my company's, crappy laptop to use defensively or to bash his brains out. John isn't moving. He still stands, in the dark, holding the knife. He has an idiotic smirk on his face. I look back at his sisters:

"That's just his sense of humor", says one of them.

 "If John gets any funnier, I'm calling 911", I return, flatly and coldly.

The knife quickly returns to John's pocket and we all wait in silence for the funeral home. There's nothing left for me to say to this family. Right now, I'm fresh out of conversation... and compassion.  I'm also busy thinking about my life insurance and disability benefits. Because one of these nights, one of these "comedians" just might get me.

Wednesday, September 3, 2008

Ghost Tour

I decided to save this one for the beginning of the school year...

These images were captured on CCTV at a high school in Asheville, North Carolina on 8/01/08. 
The first video includes news coverage of the sighting. The second video isolates the images of interest and makes it easier to replay and study them. What do you think? A real ghostie or a bug on the lens?

Here's another reason to not go to school...

Tuesday, September 2, 2008

Monday, September 1, 2008

A Little About The Job... ('Cause It's Labor Day!)

Please remember, as you read this, that I can only speak of my own job as assigned by my hospice. Hospices, throughout the country, handle their "after hours" emergency cases in many, different ways...

Many hospices rotate their day shift nurses to be "on call" at night.
Thankfully, my hospice has nurses that are dedicated only to the night shift. It's a staffing "plus" that allows the day shift nurses a full night's sleep thus allowing them to fully tend to their patients during the ususal 8A-5P hours. I truly believe that having dedicated night nurses contributes greatly to staff retention. A nurse that has devoted a full day to tending his/her patients and then has to be repeatedly "on call" during the night rapidly becomes an unhappy nurse. Unhappy nurses will soon look for work elsewhere.

I work alone, from home, and am responsible for approximately 180 patients scattered within an area of at least 1,500 square miles. At night, an on-call hospice physician and nursing supervisor are available if I should need them. They, of course, have also worked a long day and are surely hoping that I don't need to wake them up. I take great pride in that I rarely ever have to disturb anyone's sleep.

Some hospices assign a "back-up" to the night nurse. This nurse, from the day shift, is to assist in the event that multiple emergencies happen simultaneously. I don't have a "back-up". When all hell breaks loose, I take a deep breath, mentally triage the events and just "do it". I also very carefully explain the situation to the caregivers and assure them that they will be seen as quickly as possible. Caregivers are almost always very understanding in these situations. They also understand that the needs of the living patient will always override the needs of the dead.

Emergencies are as varied as the patients. Intractable pain, terminal restlessness,respiratory distress, malfunctioning equipment, occluded Foley caths, family "freak outs" ... the list is endless. Unfortunately, some caregivers are disappointed in my reluctance to respond. Linen changes, dirty diapers and constipation will almost never warrant a visit from an emergency night nurse.

It's a lonely and sometimes, dangerous job; but the rewards are beyond compare. The caregivers are very appreciative and relieved when I walk into their home and I'm happy to be there... because I know that I can help. I am one of the lucky few that can say, "I love my job."