Eliminating fraud requires a completely different effort from the one needed to battle waste. In the case of fraud, a criminal posing as a home care provider may stretch the truth regarding a patient’s diagnosis, ability to function and need for certain services. These folks are not beyond outright lies. In certain parts of the country, people have been caught making cash payments to Medicare beneficiaries in exchange for the use of their Medicare number. They follow this with claims for services that were never provided, to patients who are not sick. The proper response to this problem is to find these people, close their operations and throw them in jail.

In the case of waste, the cure is civil rather than criminal. Here you have honest home care providers serving patients in need of care but not properly documenting the care they provide or not clearly delineating the medical necessity for providing it. To the eye of the RHHI, and eventually the Administrative Law Judge, these payments must be denied but the perpetrators are not criminal. They are simply overworked, improperly trained or lazy.

The proper response to this problem is to educate agency management. Home health agency owners who allow such a situation to exist unchecked need to be convinced to either provide an ongoing staff training program or to ease off on their productivity requirements so that clinicians have adequate time to document properly. Payment denials should be a good way to get their attention.

The buck stops at the owner’s desk
CMS, the Center for Medicare and Medicaid Services, has no mechanism for dealing with waste differently than they deal with fraud. Fines and punishment are the only arrows in their quiver. Solving the problem by helping clinicians learn better documentation skills is the responsibility of the owner of the agency, not the payer. Yes, CMS does provide some training services. It is still up to management to make sure those courses reach the staff.

Judging by the increasing number of Medicare payments denied because of lack of medical necessity — which in practice actually means “lack of documented medical necessity” —  training has not been a priority for too many home health agencies. In fact, the problem of inadequate documentation is rampant in home care. Comprehensive training for home care nurses and therapists is far below the level needed, in spite of the fact that live and online opportunities abound.

Are there consequences? Absolutely. As Medicare’s need to cut costs grows more urgent, good clinicians offering good care with inadequate documentation are just as plum a target for auditors and investigators as full-fledged criminals. And their employers’ fates will be the same, regardless of criminal intent. Agencies unwilling to invest in ongoing, comprehensive training will see their revenue stream decrease by an amount that will dwarf what they would have spent on a comprehensive training program.

Consultants have ethical limits
Recently, we came across a shocking example of what can happen when agency owners make no effort to improve clinician skills. A consultant who has asked for anonymity, for himself and his client, shared with us a letter he wrote, explaining to a regular client why he could no longer represent them before their RHHI and the subsequent appeal levels, QICS, MACs and ALJs.

This agency had been hit with an unusual number of payment denials recently but dediced that the reason was its location within a region CMS has targeted as a high-fraud area. In spite of repeated warnings, the consultant found himself unable to make the client understand why he was able to win back payments in some cases but not in others. “Sometimes,” he told RAC Assistance, “the ALJ is right. The only evidence I can present is the clinical documentation I have been provided. When it truly is inadequate, no amount of legal argument, no matter how skilled or eloquent, can convince a judge to overturn a denial.”

With permission, and with both consultant and client identities masked, we reprint this letter in our next article: “Consultant Fires Client Over Inadequate Documentation.” Following that, under a separate headline, we also reprint some specific examples of the kind of documentation problems the consultant presented to his former client, along with his suggestions of how this client’s staff might have documented differently.

PHYSICAL THERAPY
I typically work on appeals from various regions. The following is a compilation of what I have found in 38 different physical therapy charts. Compare them to what you are doing and please realize they are all being denied all the way to the ALJ level just like yours are.

Two agencies have on their evaluation forms checkboxes indicating many of the following maladies:

• Antalgic gait a limp adopted so as to avoid pain on weight-bearing structures, characterized by a very short stance phase.
• Ataxic gait an unsteady, uncoordinated walk, employing a wide base and the feet thrown out.
• Festinating gait a gait in which the patient involuntarily moves with short, accelerating steps, often on tiptoe, as in parkinsonism.
• Helicopod gait a gait in which the feet describe half circles, as in some conversion disorders.
• Hip extensor gait a gait in which the heel strike is followed by throwing forward of the hip and throwing backward of the trunk and pelvis.
• Myopathic gait exaggerated alternation of lateral trunk movements with an exaggerated elevation of the hip.
• Quadriceps gait a gait in which at each step on the affected leg the knee hyper extends and the trunk lurches forward.
• Spastic gait a gait in which the legs are held together and move in a stiff manner, the toes seeming to drag and catch.
• Steppage gait the gait in foot drop in which the advancing leg is lifted high so that the toes can clear the ground.
• Stuttering gait one characterized by hesitancy that resembles stuttering.

Your agency frequently creates notes such as the ones I received for one patient:

• “Was in hospital for bronchitis, had decline in function.”
  • Which functions? How can one tell?
• Living situation “capable”
• Pain: = 0
  • Why are we in this home?
• Prior Level of function: “Independent”
  • How does “independent” differ from “capable?”
• Posture: “Kyphotic”
  • To what extent? And how is it adversely affecting the patient?  This is never again mentioned in any note. Where did the posture issue go?
• Full weight bearing, with standby assistance.
• Quality/Deviations/Postures: “Decreased endurance with ambulation”

This is the logical place for any of the aforementioned abnormalities to be recorded. Detail on these brief notes would go far when it comes time to defend a denial of payment for this patient. Poor endurance with walking is the primary driver for the care to be delivered but I know that from talking with this therapist. I could not know it from these notes.

SKILLED NURSING
This example leaves a judge not only with a suspicion that this nurse was practicing documentation cloning but also that the patient’s welfare was placed in jeopardy due to the nurse’s lack of response .

Skilled nursing visit dated January 18, 2009 9:00 AM
the skilled nurse focused on the new diabetes regimen with the change doses three times a day with the insulin, and assess compliance and effectiveness of the antibody therapy that was completed on January 17 to assure that no side effects or adverse reactions occurred. Blood sugar of 180 MG/DL, which is approximately 80 points higher than the normal range. It is to be expected that the patient’s blood sugar will come down with the new medication regimen but an infection and the stress of being in the hospital can elevate blood sugars and is a very common side effect of the patient’s illness.

Skilled nursing visit January 20, 2009
demonstrates the blood sugar is now 216 MG/DL, which is 116 points above normal, and the patient is hypertensive at 184/94. Before leaving the house, the patient’s blood pressure was reported as being 150/80.

Skilled nursing visit January 22, 2009 at 10:15 AM
blood sugar continues to climb at 289, which is 189 points above normal. Blood pressure is 170/80 in the right arm left arm records 165/80.

Skilled nursing visit January 27, 2009 8:00 AM
the patient is still experiencing difficulty with blood sugar levels as level as noted to be 305MG/DL

Skilled nursing visit January 30, 2009 10:30 AM
the patient continues to have challenges with the diabetic regimen, blood pressure 159/76 as noted in the right arm and left arm 155/80. Skilled nurse continues to check the patients for signs or symptoms of hyperglycemia yet the patient states that she is feeling fine, the caregiver verbalize that she is comply with blood sugar checking in insulin management has ordered. The skilled nursing instructed the caregiver on the purposes and action of humulan insulin and reinforced the need to monitor the diet and the blood sugar to achieve optimal results with the new medical regimen.

Skilled nursing visit February 3, 2009 9:30 AM; the nurse notes the blood pressure to be elevated at 165/99; when queried the patient denies symptoms of hypertension, the nurse reported the findings to the case manager and M.D. The M.D. decided not to deliver any new orders.

Skilled nursing visit dated February9, 2009 12:00 PM; patient’s blood pressure continues be 156/578 on the right arm 155 are in the left arm with a blood sugar of 280 mg/dl.

Skilled nursing visit dated March 1, 2009 1:15 PM; blood sugar of 264 milligrams/DL.

Analysis: This nurse admits in this six-week narrative that she waited until February 3 to alert the physician of a patient who had been spiraling out of control since January 18. My conclusion not enough was done for this patient. This type of documentation is rampant in your agency’s notes but is not being managed by case managers or the QA staff. As owners, you must ask why not.

It is this type of documentation that leaves you wide open for a continuous series of post payment reviews. Medical necessity is not clearly defined; patient’s conditions are not being responded to; yet bills for services continue to be submitted. Every agency that allows this to go on has a limited life expectancy. I fear yours is nearing its end unless ownership attends to these patterns.

Two nurses have won recognition as emerging leaders in the field of nursing informatics, selected by the Alliance for Nursing Informatics (ANI) to participate in a jointly supported Nursing Informatics Emerging Leaders Program. The two nurses recognized as emerging leaders are Ellen Makar, RN-BC, MSN, of Yale–New Haven Health System, Connecticut and Sandra Ng, RN-BC, MSN, UCSF Medical Center, part of the University of California, San Francisco.

ANI and its Nursing Informatics Emerging Leaders Program are jointly supported by the American Medical Informatics Association (AMIA) and the Healthcare Information and Management Systems Society (HIMSS). To fulfill their commitment to the program, each Emerging Leader is expected to:

1. complete a nursing informatics leadership project
2. attend meetings of the ANI governing directors
3. participate in the HIMSS Annual Conference and Exhibition (March 1-4, 2010), including its Nursing Informatics Symposium, and
4. participate in the AMIA Annual Symposium (Nov. 13-17, 2010).

Makar and Ng were selected through a process based on multiple criteria:

• holding a mid-level position in informatics in a health care setting
• holding a current license to practice as a registered nurse
• demonstrating the ability to make a difference as a leader in the field of informatics.

This inaugural program aims to develop leaders capable of assuming national leadership positions in an informatics-related organization. Ellen Makar currently serves as a clinical coordinator in the decision support department at Yale–New Haven Health, where she retrieves and analyzes administrative health data for projects that require operational, clinical, and financial decision-making. She is also a doctoral student at Goldfarb School of Nursing at Barnes Jewish College in St Louis, Missouri.

She will be paired with two mentors: Bonnie Westra, Assistant Professor at the University of Minnesota School of Nursing; and Carol Petersen, Manager, Perioperative Informatics, at the Association of periOperative Registered Nurses. Westra formerly served as clinical advisor to CareFacts Information Systems, the home care and hospice software vendor headquartered in St. Paul, Minnesota.

Sandra Ng is currently responsible for operating trials of ground-breaking hardware and applications in a clinical setting, redesigning workflow processes, and evaluating impact of these innovations on various clinician workflows during routine patient care. During her involvement in the two-year leadership program, Ms. Ng will be mentored by HIMSS Vice President of Informatics Joyce Sensmeier and Curtis Dikes, National Director, Clinical Informatics Technology Integration at Kaiser Permanente.

“Clinical workflow design and processes are the foundation of quality patient care with nurses focused on providing both effective and efficient care to their patients,” said Ms. Sensmeier. “Through this mentoring program, nurses are introduced to the benefits of care collaboration and clinical informatics in nursing so that they can step in as the future leaders of the nursing profession.”

ANI is co-sponsored by AMIA and HIMSS to represent nursing informatics with a unified voice, while providing synergy and structure needed to advance the efforts of nursing informatics professionals in improving delivery of patient care. ANI represents more than 5,000 nurses, brings together 26 distinct nursing informatics groups, integrates nurses from a broad swath of academia, practice, industry and a variety of specialty areas, working collaboratively with nearly three million nurses practicing in the United States.

http://www.allianceni.org

About HIMSS

The Healthcare Information and Management Systems Society is a comprehensive healthcare-stakeholder membership organization exclusively focused on providing global leadership for the optimal use of information technology (IT) and management systems for the betterment of healthcare. Founded in 1961 with offices in Chicago, Washington D.C., Brussels, Singapore, and other locations across the United States, HIMSS represents more than 23,000 individual members, of which 73% work in patient care delivery settings. HIMSS also includes over 380 corporate members and nearly 30 not-for-profit organizations that share its mission of transforming healthcare through the effective use of information technology and management systems. HIMSS frames and leads healthcare public policy and industry practices through its educational, professional development, and advocacy initiatives designed to promote information and management systems’ contributions to ensuring quality patient care.

www.himss.org

About AMIA

The American Medical Informatics Association is a member-supported professional association of leaders advancing biomedical and health informatics in the United States. AMIA supports the development and application of informatics in patient care, public health, human life sciences, education, research, administration and health care-related policy. AMIA’s 4,000 members advance the use of health information and communications technology with the ultimate goal of improving health and healthcare systems.

www.amia.org

In the second excerpt, we were particularly interested in their evidence that low-tech telemedicine, using a telephone, can make measurable changes in physical and emotional improvement for post-op heart patients. The third one, we readily admit, is a bit self-serving. Like most office workers, we have been looking for an excuse to feel less guilty about how much coffee is ingested around here.

JAMA sends us regular news flashes. We will continue to keep an eye out for relevant items.

JAMA Launches New Series on Caring of the Aging Patient

CHICAGO – 12/29/09 – JAMA is launching a new series, “Care of the Aging Patient: From Evidence to Action.”

“The aging of the global population will be a hallmark of the 21st century, when average lifespan may reach 100 years in some countries, at least for women. Worldwide, the proportion of the population aged 60 years or older is expected to increase from 10 percent worldwide in 2005 to 22 percent in 2050, with the steepest rise in the next 25 years. Individuals aged 85 years or older are the most rapidly increasing segment of many populations,” according to an editorial in the December 23/30 issue of JAMA.

C. Seth Landefeld, M.D., of the University of California, San Francisco, and colleagues write that aging will shape the lives of patients and the practice of medicine, and that physicians will spend more time caring for older individuals. “Although physicians are knowledgeable about the pathophysiology, diagnosis, and management of organ-specific diseases such as cataract, coronary artery disease, and pneumonia, many geriatric syndromes are not straightforward and do not fit the conventional paradigm of disease.”

“The Institute of Medicine’s 2008 report Retooling for an Aging America concluded, ‘The health care workforce … is not prepared to deliver the best care to older patients.’ This new series takes a step to address this problem.”

The overall goal of this series will be to help improve clinical practice and inform policy in care of older individuals, especially those who have started to lose their independence or are at risk of doing so. “Using the real stories of patients and interviews with them, the new series will analyze how to put existing evidence into practice to address pressing questions that arise for older patients, their families, and their physicians. By focusing on older patients’ specific problems, the articles will explore themes that develop with aging,” the authors write.

The first 12 articles will explore the course of aging, from the first hints of frailty through events such as difficulty driving a car to the progressive restriction of activities that results from a steady decline. “The series aims to provide clinicians with pragmatic tools and methods for translating published evidence into daily practice, or if evidence does not exist, recommendations with a rationale and a potential research agenda.”

In the first article in the series, David Reuben, M.D., of the University of California, Los Angeles, discusses the approach to care of older patients beginning with a consideration of life expectancy and patient goals. Such an approach helps tailor the patient’s visit to issues of greatest importance to the patient and interventions to maximize prevention, independence, and quality of life. An accompanying commentary by Christine Cassel, M.D., President of the American Board of Internal Medicine, addresses necessary changes in workforce support for primary care, training requirements, payment reform, research, and systems to improve care of older adults.

This new series is made possible by funding from The SCAN Foundation.

Telephone-Delivered Care for Treating Depression After Coronary Artery Bypass Graft Surgery Appears to Improve Outcomes

CHICAGO – 12/29/09 – Patients who received telephone-delivered collaborative care for treatment of depression after coronary artery bypass graft surgery reported greater improvement in measures of quality of life, physical functioning and mood than patients who received usual care, according to a study in the November 18 issue of JAMA.

Coronary artery bypass graft (CABG) surgery is one of the most common and costly medical procedures performed in the United States. As many as half of CABG patients report depressive symptoms after surgery, and are also more likely to experience a decreased health-related quality of life (HRQL) and functional status, according to background information in the article.

Several trials for treatment of depression have been conducted in cardiac populations, but most achieved less than anticipated benefits with regard to reducing mood symptoms. “Moreover, none used the proven effective collaborative care approach recently recommended by a National Institutes of Health expert consensus panel,” the authors write. Collaborative care emphasizes a flexible real-world treatment package that involves active follow-up by a nonphysician care manager who adheres to evidence-based treatment protocols.

Bruce L. Rollman, M.D., M.P.H., of the University of Pittsburgh School of Medicine, and colleagues conducted a randomized trial to test the effectiveness of telephone-delivered collaborative care for post-CABG depression vs. usual physician care. The study included 302 post-CABG patients with depression (150, intervention; 152, usual care) and a comparison group of 151 randomly sampled post-CABG patients without depression, recruited between March 2004 and September 2007, and observed as outpatients until June 2008. Measures of HRQL, mood symptoms, functioning status and hospital readmissions were gauged via various surveys or tests.

Intervention patients received eight months of telephone-delivered collaborative care, in which a nurse care manager telephoned patients to review their psychiatric history, provide basic psychoeducation about depression and its effect on cardiac disease, and describe treatment options. The nurses worked with patients’ primary care physicians and were supervised by a psychiatrist and primary care physician from this study.

The researchers found that intervention patients reported greater improvements in mental HRQL, physical functioning and mood symptoms. Overall, 50 percent of intervention patients reported a 50 percent or greater reduction in mood symptoms from baseline to 8-month follow-up vs. 29.6 percent of patients in usual care. “Men with depression were particularly likely to benefit from the intervention. However, the mean HRQL and physical functioning of intervention patients did not reach that of the nondepressed comparison group,” the authors write.

“Since a substantial minority of patients did not benefit from our depression intervention, it is vital to identify post-CABG patients most likely to become treatment resistant so as to develop more effective treatments for them. Identifying the intervention components that maximally contribute to our outcomes is also of great interest. However, collaborative care is a complex intervention involving a number of separate mechanisms that have proven difficult to disentangle from the nonspecific effects of increased attention by the care manager.”

“Additional research is necessary to develop improved treatments for women and patients with resistant depression, and to examine the economic effect of this intervention,” the researchers conclude.

Regular Coffee, Decaf and Tea All Associated With Reduced Risk for Diabetes

CHICAGO – 12/29/09 – Individuals who drink more coffee (regular or decaffeinated) or tea appear to have a lower risk of developing type 2 diabetes, according to an analysis of previous studies reported in the December 14/28 issue of Archives of Internal Medicine.

By the year 2025, approximately 380 million individuals worldwide will be affected by type 2 diabetes, according to background information in the article. “Despite considerable research attention, the role of specific dietary and lifestyle factors remains uncertain, although obesity and physical inactivity have consistently been reported to raise the risk of diabetes mellitus,” the authors write. A previously published meta-analysis suggested drinking more coffee may be linked with a reduced risk, but the amount of available information has more than doubled since.

Rachel Huxley, D.Phil, of The George Institute for International Health, University of Sydney, Australia, and colleagues identified 18 studies involving 457,922 participants and assessing the association between coffee consumption and diabetes risk published between 1966 and 2009. Six studies involving 225,516 individuals also included information about decaffeinated coffee, whereas seven studies with 286,701 participants reported on tea consumption.

When the authors combined and analyzed the data, they found that each additional cup of coffee consumed in a day was associated with a 7 percent reduction in the excess risk of diabetes. Individuals who drank three to four cups per day had an approximately 25 percent lower risk than those who drank between zero and two cups per day.

In addition, in the studies that assessed decaffeinated coffee consumption, those who drank more than three to four cups per day had about a one-third lower risk of diabetes than those who drank none. Those who drank more than three to four cups of tea had a one-fifth lower risk than those who drank no tea.

“That the apparent protective effect of tea and coffee consumption appears to be independent of a number of potential confounding variables raises the possibility of direct biological effects,” the authors write. Because of the association between decaffeinated coffee and diabetes risk, the association is unlikely to be solely related to caffeine. Other compounds in coffee and tea—including magnesium, antioxidants known as lignans or chlorogenic acids—may be involved, the authors note.

“If such beneficial effects were observed in interventional trials to be real, the implications for the millions of individuals who have diabetes mellitus, or who are at future risk of developing it, would be substantial,” they conclude. “For example, the identification of the active components of these beverages would open up new therapeutic pathways for the primary prevention of diabetes mellitus. It could also be envisaged that we will advise our patients most at risk for diabetes mellitus to increase their consumption of tea and coffee in addition to increasing their levels of physical activity and weight loss.”

JAMA added this editor’s note: Dr. Huxley is supported by a Career Development Award from the National Heart Foundation of Australia. This work was additionally supported by a grant from the National Health and Medical Research Council of Australia; a Research Career Development Fellowship from the UK Wellcome Trust; and a research grant from Institut Servier, France and Assistance Publique-Hopitaux de Paris. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Nevertheless, searching the literature and the web for those best practices can be both confusing and time consuming. The most important component when finding and using best practices, especially including research- and evidence-based practice, is being sure they are valid and reliable, knowing they can be used with confidence and are current and will help you direct patient care.

Over the past three years, the Collaboration for Homecare Advances in Management and Practice – CHAMP – has increasingly become a valuable resource for home care clinicians, clinical, quality improvement and educational managers, educators, as well as anyone else interested in advancing home care clinical practice and patient outcomes.

Administered by the Center for Home Care Policy & Research, a part of the Visiting Nurse Service of New York, you can be confident the information is reliable. Add the CHAMP program web site to your Internet Favorites. Use it as a go-to resource for agency policies and procedures. Have confidence in the support you will find there in the questions and answers from peers and consultants.

CHAMP’s web site http://www.champ-program.org/ provides:

• A broad, web-based community where members can interact with other home care professionals and experts and gain access to information on the latest performance improvement innovations and updates http://www.champ-program.org/page/57/champ-community

• Downloadable tools, presentations and guidelines in the Resources section http://www.champ-program.org/page/40/resources

• Affordable, self-paced online educational programs to enhance frontline manager and staff skills http://www.champ-program.org/page/39/programs-learning

• Evidence-based, best practice information provided by evidence briefs summarizing the nation’s first consistent geriatric practice framework for home care http://www.champ-program.org/page/56/framework

Many agencies have used CHAMP resources. A Clinical Nurse Specialist of a large home health agency commented, “I have to tell you it is fabulous…The amount of info, the quality of info is unbelievable…one terrific web site!”

Laurie Reische, CHAMP Program Manager, told an IHCC interviewer, “It is exciting to be able to bring CHAMP to home care organizations and stakeholders all over the country. Now home care organizations and staff have a place to easily access evidence-based resources and best practices that specifically address the complex needs of older home care patients.”