Medicare Probe

OneThunder, BSN, RN · Dec 17, 2007

OneThunder...
That is a separate issue.
Just as in the article in question, where a hospice nurse spends her day helping the elderly, rural poor manage their meds and turn sweet potatoes in the oven. That is all very nice and no doubt, necessary. However, hospice was not invented and designed for the purpose of turning sweet potatoes... nor for relieving nursing homes of the responsibility of hiring sufficient staff and training them properly.
Using hospice for something other than what it was intended damages hospice in the long run.
Michael

Be that as it may, it is reality. LTC facilities budgets are limited by their corporations. They hire and train as they are budgeted for. We can point fingers all day to whose fault it is, but that is NOT assisting the dying patient in the nursing home. And that what hospice was intended to do. Help the dying patient.

req_read · Dec 17, 2007

OneThunder…

Actually hospice was originally designed to care for dying people in their home. It was not until some time later that hospice was given the go-ahead to provide services in nursing homes.

No… I have never worked in a nursing home. My first wife did. One of the homes she worked for (for a short while) was owned by a group of physicians who were more interested in making a buck than in providing good care. There were strange goings on there from time to time as well (which I won’t go into) but I’m sure most nursing homes are good.

Still, when hospice came into nursing homes it gave the corporations who own them a golden opportunity; i.e. the opportunity to limit their staff and staff training, thus increasing their profit margin. As usual, the taxpayer foots the bill… which begs the question, “Why don’t we taxpayers just take them over?”

Your concern for your pts is admirable (and your frustration apparent.) The way we deal with (or fail to deal with) healthcare in this country is appalling. I don’t know OneThunder… maybe hospice needs to stick its thumbs and all its fingers in a variety of dikes… at least until next year’s election.

Oy!

Michael

P.S. And no… I am not a democrat. I am independent… very independent!

OneThunder, BSN, RN · Dec 18, 2007

OneThunder...
Actually hospice was originally designed to care for dying people in their home. It was not until some time later that hospice was given the go-ahead to provide services in nursing homes.
No... I have never worked in a nursing home. My first wife did. One of the homes she worked for (for a short while) was owned by a group of physicians who were more interested in making a buck than in providing good care. There were strange goings on there from time to time as well (which I won't go into) but I'm sure most nursing homes are good.
Still, when hospice came into nursing homes it gave the corporations who own them a golden opportunity; i.e. the opportunity to limit their staff and staff training, thus increasing their profit margin. As usual, the taxpayer foots the bill... which begs the question, "Why don't we taxpayers just take them over?"
Your concern for your pts is admirable (and your frustration apparent.) The way we deal with (or fail to deal with) healthcare in this country is appalling. I don't know OneThunder... maybe hospice needs to stick its thumbs and all its fingers in a variety of dikes... at least until next year's election.
Oy!
Michael
P.S. And no... I am not a democrat. I am independent... very independent!

Originally when there weren't such things as "nursing homes" (back in England, back in the day). And no, I don't think most nursing homes (or corporations for that matter) consider hospice as a way to "limit staffing". Regardless of hospice assistance or not, federal guidelines demand the same forumula including all the residents whether or not they are on hospice to calculate their staffing levels. What hospice really does, it lets the hospice aide spend a decent amount of time doing ADLs,(not rushing through to get to the next resident),do the little "extras" (paint female residents fingernails, perhaps a bit of makeup) and the Case Manager time to actually talk to the resident and/or family, do a more complete assessment without having to worry about all the call lights going off, the phone ringing, and supervising 7 or 8 nursing assistants. Hospice lets the social worker counsel patients/families in grief and loss, or guide them through the maze of financial woes. It lets the Chaplain spend time with the dying resident/family and help them make peace.

I really hope you are kidding about taxpayers taking over the nursing homes. The average Joe has no idea how nursing homes are under-reimbursed for the care they give. They just see the sensational headlines about nursing homes that the "ambulance chaser" lawyers pursue.

I don't think hospice should try to address all the problems in nursing homes. Only one. The dying resident who wishes to have hospice care at the end of their lives. Just because they happen to live in a facility, shouldn't prevent them from the benefit of hospice care.

req_read · Dec 19, 2007

OneThunder…

I must confess that I am not sure what your point is… other than being against anything I say. As near as I can tell you seem to be saying that the status quo with hospice & nursing homes is just fine. Others contributing to this forum have reported things like nursing homes having the same medical director as hospices who then refer and recertify patients inappropriately and wind up pushing hospice lengths of stay over their caps which in some cases may lead to hospice agencies going bankrupt and out of business. Statistical data collected by and for Medicare shows a certain percentage of clear abuse by some hospice agencies, some of whom are working hand-in-glove with nursing homes. And you think this is all okay? Are you suggesting that posters on this forum who report abuse are all wrong? Or are you saying that abuse is perfectly fine?

Should for-profit nursing homes not be held accountable for providing adequate staff to care for their patients? If nursing home corporate boards decide not to staff adequately should it then become the government’s responsibility (via Medicare) to cover whatever nursing homes choose not to? Should nursing homes not be required to train their staff in things like dying process?

Nurses working in hospitals are pushed to their limit too. When there are dying patients in hospitals should Medicare then pay for hospice nurses to go into hospitals… because the nurses and aids there are busy taking care of other pts? Are you suggesting that only hospice nurses should care for the dying?

That is a thought… now that I think about it. Maybe they should? I mean, I wouldn’t want an L&D nurse giving me chemo.

My allusion to taxpayers taking over was in reference to a possible nationalized healthcare system, not nursing homes alone. In the current system we have programs for this and programs for that but if a patient does not fall into a particular program s/he simply falls through the cracks. Presumably at least, a nationalized healthcare system would have no cracks to fall through. Care would be provided whether the pt fit a particular program or not. As currently conceived & practiced we have things like nursing homes (with nurses) who either do not have the time or training to provide nursing care to their pts, so nurses from a different program are sent in to provide nursing care in nursing homes. The system does seem unduly chaotic… layer upon layer of stop-gap programs with no overall plan (a lot like our cities have been constructed.)

You say, “The average Joe has no idea how nursing homes are under-reimbursed for the care they give.” Okay, enlighten us.

My understanding is that there are all different kinds of “nursing homes,” e.g. privately owned for-profit homes, State owned not-for-profit homes, private homes that cater to wealthy clients, and other homes that have been in business since forever and just try to get by. Actually my father is currently in a nursing home. They charge quite a lot of money for his care and their nurses & aids do not seem to be overly harried.

You speak about nursing homes as though there is only one, generic kind of nursing home. We both know that is not the case, so perhaps you might tell us about yours? Is it State owned? Privately owned? For-profit? Not-for-profit. Does your State mandate minimum staffing requirements? If so, are those requirements (in your estimation) adequate? Does your corporate board (assuming you have one) tend to provide staff as-needed, or simply staff as-required (by the regs?) Does your nursing home have a medical director? If so, is that person also medical director of a hospice agency?

Michael

OneThunder, BSN, RN · Dec 19, 2007

onethunder...
i must confess that i am not sure what your point is... other than being against anything i say.not really. as near as i can tell you seem to be saying that the status quo with hospice & nursing homes is just fine. i'm saying the nursing home resident has just as much right to end of life care as the next person others contributing to this forum have reported things like nursing homes having the same medical director as hospices who then refer and recertify patients inappropriately and wind up pushing hospice lengths of stay over their caps which in some cases may lead to hospice agencies going bankrupt and out of business. statistical data collected by and for medicare shows a certain percentage of clear abuse by some hospice agencies, some of whom are working hand-in-glove with nursing homes. and you think this is all okay? actually i checked back at all of my posts, i never said anything of the kind. are you suggesting that posters on this forum who report abuse are all wrong? or that either. or are you saying that abuse is perfectly fine?now you sound like a politian.
should for-profit nursing homes not be held accountable for providing adequate staff to care for their patients?according to medicare guidelines, they are if they are taking medicare money. if nursing home corporate boards decide not to staff adequately should it then become the government's responsibility (via medicare) to cover whatever nursing homes choose not to? no, it's called citations and fines. no nursing home (profit or not for profit can stay in business if they are continually being cited and fined for staffing issues.and then there is the matter of the quality indicators that are allowed to be publicly published in newspapers. like any business, poor ratings beget less business,beget closing the doors. should nursing homes not be required to train their staff in things like dying process?even if they do, they can not provide the one on one care that hospice provides for a dying patient.
nurses working in hospitals are pushed to their limit too. this i realized when i worked in both a rural hospital and an urban hospital. when there are dying patients in hospitals should medicare then pay for hospice nurses to go into hospitals... i'm sure you realize that they do, it's called general inpatient level of care. several hospitals in my area have contracts with hospices to provide general inpatient level of care.because the nurses and aids there are busy taking care of other pts? are you suggesting that only hospice nurses should care for the dying?
that is a thought... now that i think about it. maybe they should? i mean, i wouldn't want an l&d nurse giving me chemo. you make my point.
my allusion to taxpayers taking over was in reference to a possible nationalized healthcare system,now there is an idea. maybe like canada's socialized medicine where patients die on a waiting list for a bypass. if national healthcare is such a good deal, i wonder why there are so many canadian doctors jumping the border to work in the us? probably the frustration of not being able to be true to the hypocratic oath. not nursing homes alone. in the current system we have programs for this and programs for that but if a patient does not fall into a particular program s/he simply falls through the cracks.i can appreciate your concern for those patients, but our constitution does not have a provision that gives any citizen the right to health care.simple as that. i realize i have opened a can of worms, and most people do not agree. but it is fact. presumably at least, a nationalized healthcare system would have no cracks to fall through. care would be provided whether the pt fit a particular program or not. as currently conceived & practiced we have things like nursing homes (with nurses) who either do not have the time or training to provide nursing care to their pts, so nurses from a different program are sent in to provide nursing care in nursing homes.if the nursing home resident needs specialized care, (physical therapy, occupational therapy, respiratory therapist, advanced wound therapy, our system sends in the specialist. why do you consider hospice so different? the system does seem unduly chaotic... layer upon layer of stop-gap programs with no overall plan (a lot like our cities have been constructed.)
you say, "the average joe has no idea how nursing homes are under-reimbursed for the care they give." okay, enlighten us. see below.
my understanding is that there are all different kinds of "nursing homes," e.g. privately owned for-profit homes, state owned not-for-profit homes, private homes that cater to wealthy clients,most likely they are private pay also, not taking medicare or medicaid money. and other homes that have been in business since forever and just try to get by. actually my father is currently in a nursing home. they charge quite a lot of money for his care and their nurses & aids do not seem to be overly harried. there is a reason nursing home staff refers to their survey as "state". there are federal guidelines, but the states dole out the payments, and there is an inequity in payments depending upon the region. outlyers recieve less per resident than others.(at least, that is how my state did it when i was in long term care).this "all encompassing medicad payment must include, room board, medicine (aside from labor, this is the most expensive) wound care, restorative care, activities, etc. at one point i remember our outlying facility recieved $89 per day for a resident. start adding up nurse hours, aid hours, housekeeping hours, dietary/cook hours, maintence hours and it was no wonder the per capita rate had to be raised, too many nursing homes were going out of business and no one to care for the elderly. now medicare will cover "skilled" care (ie, 3 day hospital stay, with the need for therapies, at 100% but only for 20 days. the rest comes in at 80% with the resident or family being responsible for the co-pay) most can not afford this for the rest of the "100 days" that the hospitals assures the resident and family that medicare pays for.
you speak about nursing homes as though there is only one, generic kind of nursing home. if they take gov't money, they must follow federal guidelines. we both know that is not the case, so perhaps you might tell us about yours? i dont have one. i haven't been in long term care for a long time. is it state owned? some privately owned? a few for-profit? most, although fyi a profit margin of 4% is about average for nursing homes not-for-profit. one in my area that i have visited does your state mandate minimum staffing requirements? yes, without a doubt if so, are those requirements (in your estimation) adequate?for the most part, yes, but i have also seen those that can not keep those levels up for very long due to the cost, so, unfortunately other areas suffer, most notably dietary. does your corporate board (assuming you have one) tend to provide staff as-needed, or simply staff as-required (by the regs?) "my" corporate board puts the patients and their families first as stated in our service standardsdoes your nursing home have a medical director? i don't have a nursing home, but yes, we have a medical director if so, is that person also medical director of a hospice agency?
michael

what you seem to think is obscene, i see as a "continuum of care". what the resident needs, therapies, wound care, respiratory care, is almost always provided by outside services that come into the nursing home to give the resident the specialized care that they require. why is it, that hospice is looked upon differently?

there are processes or procedures, if you will, in place by medicare. violations/infractions are delt with.should they be stronger? should the system be changed? are there more nursing homes doing things right than those that make the media who do things wrong?

all in all, i maintain the nursing home resident has the same right as anyone else to end of life care. this "specialized" care is hospice.

req_read · Dec 19, 2007

OneThunder…

No, the constitution does not give Americans, as you say, the RIGHT to healthcare. Neither does it give nursing home patients the RIGHT to hospice care.

It is interesting the way you portray nursing homes as being highly regulated with such narrow profit margins… to the point where their nursing staffs do not have time to provide one-on-one care, then eschew considering more comprehensive systems based on your political bias. Your position seems to be that if Canada cannot operate an effective nationalized healthcare system (which is highly debatable… nowhere near as simplistic as you describe) then it would naturally follow that we Americans could not do it either. Following that logic, if the Russians cannot operate an effective democracy, then neither could we Americans.

When I wondered whether hospice nurses should go into hospitals to attend the dying I was speaking about all the dying patients in hospitals, not just hospice patients placed there temporarily for either symptom control or respite care.

Your description of the narrow financial parameters within which nursing homes must operate (“FYI a profit margin of 4% is about average for nursing homes.”) which then forces cutbacks in other areas (“but I have also seen those that can not keep those levels up for very long due to the cost, so, unfortunately other areas suffer, most notably dietary.”) suggests that there are problems within the nursing home industry and its reimbursement system. (Also, it is not “dietary” that suffers, it is the patients.) If there is a problem in the nursing home industry then it seems logical that the best way to deal with it is within the nursing home industry… as opposed to slapping a hospice patch on a nursing home problem. That is just another example of what I mentioned earlier; i.e. layer upon layer of stopgap, quick fixes with no overall plan.

Historically, nurses did it all… the various therapies, like applying leeches, setting up oxygen, cleaning & sharpening needles etc. Little by little different specialties have come along, and of course made rules protecting their turf (a nurse can’t plug in and oxygen flow meter, RT must be summoned.) Have we now reached the point where only hospice nurses can deal with death & dying? Certainly it is our specialty, but if we accept your (OneThunder’s) contention that nursing home patients have a right to hospice care, then it would follow that all dying patients do as well, regardless of their location; e.g. non-hospice patients in hospitals etc. In which case, the whole hospice system would need to be re-invented.

Maybe it should be. Hm-m-m-m-m.

And whether you like it or not, some sort of nationalized healthcare system may very well be in our not-too-distant future. In which case, then what would/should hospice look like?

Michael

Sabby_NC · Dec 19, 2007

What you seem to think is obscene, I see as a "continuum of care". What the resident needs, therapies, wound care, respiratory care, is almost always provided by outside services that come into the nursing home to give the resident the specialized care that they require. Why is it, that hospice is looked upon differently?

There are processes or procedures, if you will, in place by Medicare. Violations/infractions are delt with.Should they be stronger? Should the system be changed? Are there more nursing homes doing things right than those that make the media who do things wrong?

All in all, I maintain the nursing home resident has the same right as anyone else to end of life care. This "specialized" care is hospice.

Amen Michael.

OneThunder, BSN, RN · Dec 19, 2007

onethunder...
no, the constitution does not give americans, as you say, the right to healthcare. neither does it give nursing home patients the right to hospice care. no it does not, but then you run the risk of providing healthcare on the basis of geographical location which is discriminitory. that is illegal for insurance companies and medicare/medicaid funded programs.
it is interesting the way you portray nursing homes as being highly regulated with such narrow profit margins... well, yes it is. back in the 80's long term care was the second only to nasa in regulations. with the nasa program scaling down,and the provision of care to the elderly, ltc may be the highest regulated industry in the us.to the point where their nursing staffs do not have time to provide one-on-one care, i'm sure they can provide one on one care-in fact i have seen it many times-but it is at the risk of decreasing care to the other residents. i also see care reimbursed based on documentation (and there you go taking the caregiver away from the bedside) the last i looked, they are reimbursed for bathing, feeding, medication administration (to the point of counting how many meds a resident has) but no, there is no reimbursement for sitting with a dying patient. i supposed the social worker at the facility can provide counseling for residnt and/or family, but i don't see it happening at 2am.whereas the staff can simply pick up the phone and call the hospice and a nurse or hospice social worker makes a visit.then eschew considering more comprehensive systems based on your political bias. not political bias. good common fiscal sense. your position seems to be that if canada cannot operate an effective nationalized healthcare system (which is highly debatable... nowhere near as simplistic as you describe)no not my opinion but "a study by the heart and stroke foundation of canada found that heart attack survivors in canada, a nation with a publicly-funded health care system, have a dramatically lower quality of life than their american counterparts." and "[a 2006 study by nadeen esmail and michael walker of the fraser institute also found that canadians are more likely than citizens of most other developed countries to experience long waiting lists for medical care, and that access to doctors is comparatively difficult; the study criticized the canadian model of universal health care, in which health insurance is a government monopoly.overall, statistics have suggested that the overall care quality is worse in canada than the united states; for example, canada had only 2.1 practicing physicians per 1000 people in 2004, compared to 2.4 in the united states, and in 2003, twice as many in-patient surgical procedures were performed in the united states per 1000 people as in canada.
/color] then it would naturally follow that we americans could not do it either. following that logic, if the russians cannot operate an effective democracy, then neither could we americans.fyi we are not technically a democracy, we are a republic, but that is another discussion.
when i wondered whether hospice nurses should go into hospitals to attend the dying i was speaking about all the dying patients in hospitals,one of the guidelines for hospice care is that the patient/family must want/choose hospice care.they can stay in the hospice on general inpatient if it is not in the best interest of the patient's condition to transport them on the basis of their condition. not just hospice patients placed there temporarily for either symptom control or respite care.
your description of the narrow financial parameters within which nursing homes must operate ("fyi a profit margin of 4% is about average for nursing homes.") which then forces cutbacks in other areas ("but i have also seen those that can not keep those levels up for very long due to the cost, so, unfortunately other areas suffer, most notably dietary.") suggests that there are problems within the nursing home industry and its reimbursement system. (also, it is not "dietary" that suffers, it is the patients.)financially speaking, it is the dietary department. if there is a problem in the nursing home industry then it seems logical that the best way to deal with it is within the nursing home industry...and they are. pacs are actively working to sort out arbitrary laws and guidelines as opposed to slapping a hospice patch on a nursing home problem. you continually wish to use hospice as a panacea for ltc facility woes. i continually point out that it's not about the facility, it's about the patient's choice to recieve hospice care wherever they live. again, it is illegal to "redline" the provision of care based on a patients location. now, they can only choose one program of care, ie curative vs palliative. medicare will pay for one or the other. that is just another example of what i mentioned earlier; i.e. layer upon layer of stopgap, quick fixes with no overall plan.
historically, nurses did it all... the various therapies, like applying leeches, setting up oxygen, cleaning & sharpening needles etc. little by little different specialties have come along, and of course made rules protecting their turf (a nurse can't plug in and oxygen flow meter, rt must be summoned.) have we now reached the point where only hospice nurses can deal with death & dying? of course not, but as you pointed out earlier, you don't want an l&d nurse administering your chemo. certainly it is our specialty, but if we accept your (onethunder's) contention that nursing home patients have a right to hospice care, then it would follow that all dying patients do as well, regardless of their location; e.g. non-hospice patients in hospitals etc. in which case, the whole hospice system would need to be re-invented.the whold hospice system in dynamic, not static. hospice has evolved to be able to stay true to their mission, to comfort and treat symptoms to provide for a comfortable death.it has evolved to include specialized pycho/social, volunteer,and spiritual care for not only the patient but the family also. hospice continues to address the issues facing patients and families at end of life. hospice will continue to evolve, providing relief from suffering, treatment of pain and other distressing symptoms, psychological and spiritual care, a support system to help the individual live as actively as possible, and a support system to sustain and rehabilitate the individual's family
maybe it should be. hm-m-m-m-m.
and whether you like it or not, some sort of nationalized healthcare system may very well be in our not-too-distant future. i can only hope not, to see the quality and availabililty of healthcare diminish with a socialized medicine program in the us. in which case, then what would/should hospice look like?possibly access restricted, like you would have access restricted from those in long term care facilities.
michael

payment for medical treatment is a complex system of qualifications, whether you rely on government assistance or private insurance. hospice care is a treatment option, just like chemo, physical therapy, respiratory therapy. you must qualify for those treatment options. taking away a treatment option from someone that qualifies makes the government play god, as does restricting access to treatment. all other factors being equal, i don't want to support a healthcare system that does.

OneThunder, BSN, RN · Dec 19, 2007

onethunder...
no, the constitution does not give americans, as you say, the right to healthcare. neither does it give nursing home patients the right to hospice care. no it does not, but then you run the risk of providing healthcare on the basis of geographical location which is discriminitory. that is illegal for insurance companies and medicare/medicaid funded programs.
it is interesting the way you portray nursing homes as being highly regulated with such narrow profit margins... well, yes it is. back in the 80's long term care was the second only to nasa in regulations. with the nasa program scaling down,and the provision of care to the elderly, ltc may be the highest regulated industry in the us.to the point where their nursing staffs do not have time to provide one-on-one care, i'm sure they can provide one on one care-in fact i have seen it many times-but it is at the risk of decreasing care to the other residents. i also see care reimbursed based on documentation (and there you go taking the caregiver away from the bedside) the last i looked, they are reimbursed for bathing, feeding, medication administration (to the point of counting how many meds a resident has) but no, there is no reimbursement for sitting with a dying patient. i supposed the social worker at the facility can provide counseling for residnt and/or family, but i don't see it happening at 2am.whereas the staff can simply pick up the phone and call the hospice and a nurse or hospice social worker makes a visit.then eschew considering more comprehensive systems based on your political bias. not political bias. good common fiscal sense. your position seems to be that if canada cannot operate an effective nationalized healthcare system (which is highly debatable... nowhere near as simplistic as you describe)no not my opinion but "a study by the heart and stroke foundation of canada found that heart attack survivors in canada, a nation with a publicly-funded health care system, have a dramatically lower quality of life than their american counterparts." and "a 2006 study by nadeen esmail and michael walker of the fraser institute also found that canadians are more likely than citizens of most other developed countries to experience long waiting lists for medical care, and that access to doctors is comparatively difficult; the study criticized the canadian model of universal health care, in which health insurance is a government monopoly.overall, statistics have suggested that the overall care quality is worse in canada than the united states; for example, canada had only 2.1 practicing physicians per 1000 people in 2004, compared to 2.4 in the united states, and in 2003, twice as many in-patient surgical procedures were performed in the united states per 1000 people as in canada.
then it would naturally follow that we americans could not do it either. following that logic, if the russians cannot operate an effective democracy, then neither could we americans.fyi we are not technically a democracy, we are a republic, but that is another discussion.
when i wondered whether hospice nurses should go into hospitals to attend the dying i was speaking about all the dying patients in hospitals,one of the guidelines for hospice care is that the patient/family must want/choose hospice care.they can stay in the hospice on general inpatient if it is not in the best interest of the patient's condition to transport them on the basis of their condition. not just hospice patients placed there temporarily for either symptom control or respite care.
your description of the narrow financial parameters within which nursing homes must operate ("fyi a profit margin of 4% is about average for nursing homes.") which then forces cutbacks in other areas ("but i have also seen those that can not keep those levels up for very long due to the cost, so, unfortunately other areas suffer, most notably dietary.") suggests that there are problems within the nursing home industry and its reimbursement system. (also, it is not "dietary" that suffers, it is the patients.)financially speaking, it is the dietary department. if there is a problem in the nursing home industry then it seems logical that the best way to deal with it is within the nursing home industry...and they are. pacs are actively working to sort out arbitrary laws and guidelines as opposed to slapping a hospice patch on a nursing home problem. you continually wish to use hospice as a panacea for ltc facility woes. i continually point out that it's not about the facility, it's about the patient's choice to recieve hospice care wherever they live. again, it is illegal to "redline" the provision of care based on a patients location. now, they can only choose one program of care, ie curative vs palliative. medicare will pay for one or the other. that is just another example of what i mentioned earlier; i.e. layer upon layer of stopgap, quick fixes with no overall plan.
historically, nurses did it all... the various therapies, like applying leeches, setting up oxygen, cleaning & sharpening needles etc. little by little different specialties have come along, and of course made rules protecting their turf (a nurse can't plug in and oxygen flow meter, rt must be summoned.) have we now reached the point where only hospice nurses can deal with death & dying? of course not, but as you pointed out earlier, you don't want an l&d nurse administering your chemo. certainly it is our specialty, but if we accept your (onethunder's) contention that nursing home patients have a right to hospice care, then it would follow that all dying patients do as well, regardless of their location; e.g. non-hospice patients in hospitals etc. in which case, the whole hospice system would need to be re-invented.the whold hospice system in dynamic, not static. hospice has evolved to be able to stay true to their mission, to comfort and treat symptoms to provide for a comfortable death.it has evolved to include specialized pycho/social, volunteer,and spiritual care for not only the patient but the family also. hospice continues to address the issues facing patients and families at end of life. hospice will continue to evolve, providing relief from suffering, treatment of pain and other distressing symptoms, psychological and spiritual care, a support system to help the individual live as actively as possible, and a support system to sustain and rehabilitate the individual's family
maybe it should be. hm-m-m-m-m.
and whether you like it or not, some sort of nationalized healthcare system may very well be in our not-too-distant future. i can only hope not, to see the quality and availabililty of healthcare diminish with a socialized medicine program in the us. in which case, then what would/should hospice look like?possibly access restricted, like you would have access restricted from those in long term care facilities.
michael

payment for medical treatment is a complex system of qualifications, whether you rely on government assistance or private insurance. hospice care is a treatment option, just like chemo, physical therapy, respiratory therapy. you must qualify for those treatment options. taking away a treatment option from someone that qualifies makes the government play god, as does restricting access to treatment. all other factors being equal, i don't want to support a healthcare system that does.

req_read · Dec 19, 2007

OneThunder…

Why are nursing homes so heavily regulated?

We “run the risk” of providing healthcare on the basis of geographic location all the time (which you say is discriminatory), particularly when the healthcare system is purely capitalistic in nature; e.g. there are large areas here in the west where there are no healthcare services (hospice, home health etc.) because it does not pay for providers to go there. This, in your own words, is discriminatory. It is also one more factor putting pressure on people in rural areas to move to the cities.

You obviously pick & choose which studies to believe regarding nationalized healthcare. You obsess on Canada’s system reciting only data that supports the conclusions you have already reached (which pretty well defines prejudice; i.e. to pre-judge.) Those familiar with such things who would refute your position can site just as many studies as you, demonstrating the precise opposite of what you say.

Have you studied the French system? The English system? Have you given any thought to creating an American system? Are you opposed to socialistic programs for philosophical or political reasons? You call the uneven distribution of healthcare discriminatory, but conveniently fail to recognize that the application & availability of healthcare under our current system is woefully erratic; i.e. discriminatory.

You say you have no bias against nationalized healthcare. You obviously do, but for the sake of argument… you contend that your very one-sided position is based on “good common fiscal sense.” Again, there are pros and cons to every system. One of the cons to your “good common fiscal sense” system is insurance company physicians being rewarded (financially) for denying healthcare to clients… forcing people into bankruptcy, home foreclosure etc. (when they actually have health insurance which they thought covered them.) This hardly seems like “good common fiscal sense.” Nor does forcing people to stay in jobs they detest (just so they can hang onto their health insurance… which they may discover too late does not cover them anyway) seem likely to yield a vibrant, healthy middle class and economy.

It seems more productive, at least to me, to focus on coming up with solutions rather than angrily criticizing any who try. Have you thought of some possible solutions?

On the one hand you describe the current system as flawed. When I point that out you retreat slightly, saying that nursing home nurses actually do have time to provide one-on-one care, but then throw in the caveat that if they do, other patients in the facility will be neglected. So when I ask whether, in your estimation, nursing home regs and corporate boards are providing adequate staffing your answer is both ‘yes’ and ‘no,’ depending on which argument you are pursuing at the moment.

You argue that hospice nurses (SW’s etc.) have time to spend with pt/fams and that it is a flexible system. True… to some degree anyway. But have you been reading the threads in this forum having to do with case loads ad the fact that many hospice nurses really don’t have time to sit with pt/fams? You described some of the details of nursing home documentation. Do you suppose hospice nurses do not have to document? According to posters on this forum many hospice nurses are doing their documentation on their own time, after hours, or in their cars (while missing lunch.)

Hospice does indeed have a lot going for it. Being a relatively new program its designers took a good hard look at existing systems and then tried to avoid as many of the pitfalls as they could. In other words, they learned from the mistakes that had gone before. They really were quite successful in this, but as one might expect, the business people (as opposed to pure hospice people) became more involved and influential in the evolution of hospice. One of the results of this trend has been the phenomenon of large numbers of marginally appropriate if not flat-out inappropriate hospice pts in nursing homes.

I am willing to concede that there are pts in nursing homes who are appropriate for hospice care. However, there is a very real danger here. I posed the question at the beginning of this post: Why are nursing homes so heavily regulated?

There are reasons for all the heavy regulation of course. While I have never worked in a nursing home myself I do not live under a rock. Nursing homes have historically been guilty of trying to bilk the system… the government… the taxpayer. Now (surprise!) no sooner does hospice become heavily involved with nursing homes than Medicare starts gearing up to crack down on hospice. Be careful who you associate with. Hospice’s original designers worked hard to avoid the problems that have long plagued nursing homes. Now it looks like hospice has socked that tar baby square in the nose.

Our current healthcare system is a shambles. Millions are under treated or not treated at all. Many who cannot pay actually do receive treatment (often via ER) and then those costs are spread to those who do pay (which is why an aspirin costs $20 in the hospital.) In this way, a lot of the money exchanging hands in the healthcare system is carried out under the table… and with that as a system (actually more of a non-system really) there are lots of shenanigans going on (cost-spreading, denying coverage to paying customers, inappropriate hospice admissions etc.) Why not put the money on top of the table… where we can all see it? Why not pay for what pts need instead of enriching slight-of-hand insurance company executives while denying care to pts.

One cannot make constructive change without first becoming aware of what is going on now… and unfortunately, becoming aware of what is going on now invariably involves an uncomfortable degree of honest self-evaluation. You (OneThunder) seem wholly unwilling to conduct an honest evaluation of the nursing home industry. You talk out of both sides of your mouth saying things like… nursing homes are adequately staffed, but then only if nurses neglect some patients… or no one has a RIGHT to healthcare, but nursing home pts have a right to hospice care. You adamantly defend nursing homes (even while hinting at their obvious weaknesses) and simultaneously (angrily) insist that any system other than the current one would only be worse.

I suggested that if we accept your (OneThunder) contention that nursing home pts have a right to hospice care then it would be logical to assume that all dying pts have the same right (lest we discriminate.)) For example, when a child comes into ER and dies unexpectedly (for whatever reason) should that family be penalized for not being aware their child was about to die? Should that family be denied a year’s worth of bereavement counseling? If, as I said, we accept the concept of providing care evenly across the board, then hospice will have to be re-tooled… if not entirely re-designed.

Rather than insisting that the current (broken) healthcare system is our only hope, how about considering other options… how about nursing homes considering a hospice-like model for example? If it works for us, why not for you? Of course it would be difficult to determine just what sort of per diem/capitation system would suffice for a nursing home when the waters are already muddied by the presence of a second provider, but it’s something to think about.

How about it OneThunder? Any suggestions? You argue that unevenly applied healthcare is discriminatory while at the same time angrily defending systems that are woefully and blatantly fragmentary and discriminatory. You are opposed to government “playing God,” but favor the current system which pays insurance company docs bonuses for digging up ways to deny care?

I have literally spent hours sitting in an ER waiting to be seen, wincing in pain the whole time. I worked in ER for many years and am fully aware of how long pts are frequently forced to wait. No doubt some Canadians have had similar experiences. To one degree or another that is simply the nature of the beast. The difference between me and a Canadian however is that while he is sitting there fretting over his illness, he does not also have to worry about losing his home.

Michael

OneThunder, BSN, RN · Dec 20, 2007

onethunder...
why are nursing homes so heavily regulated? that, my friend, is the $64k question.
we "run the risk" of providing healthcare on the basis of geographic location all the time (which you say is discriminatory),here you must compare apples to apples, ie, apples: patient a in a nursing home bed, pt. b at home in bed in the residential house next door.oranges: patient c in an residential home, patient d in a rual home 1600 miles away. particularly when the healthcare system is purely capitalistic in nature; e.g. there are large areas here in the west where there are no healthcare services (hospice, home health etc.) because it does not pay for providers to go there. this, in your own words, is discriminatory. it is also one more factor putting pressure on people in rural areas to move to the cities.
you obviously pick & choose which studies to believe regarding nationalized healthcare.actually,no, i chose the first couple that came up in an internet search. you obsess on canada's system reciting only data that supports the conclusions you have already reached again, actually no, i have personally worked with a few physicians that relocated from canada (oncologists and surgeons) and i remeber the horror stories they told of waiting times for treatment that were months, not minutes or hours.(which pretty well defines prejudice; i.e. to pre-judge.) which pretty well shows how you can easily cast dispersions on your opponent by call them names, and old debate club trick those familiar with such things who would refute your position can site just as many studies as you, demonstrating the precise opposite of what you say. i'm sure they can, and there are those that can just as easily refute the other side's position.
have you studied the french system? the english system? have you given any thought to creating an american system? i'd much rather fix what is broken than scrap the entire system in favor of one that is obviously also flawed. how long do you think the taxpayer can bear paying for everyone's healthcare? or should we just heavily tax the evil capitalistic corporations until they pull up roots and establish their business in another country? aren't enough jobs being sucked out of our country? are you opposed to socialistic programs for philosophical or political reasons? if being a "constitutionalist is political, then that it must be you call the uneven distribution of healthcare discriminatory, but conveniently fail to recognize that the application & availability of healthcare under our current system is woefully erratic;it is woefully erratic for many reasons: but not for lack of trying to provide access to healtcare.when i was in south dakota, a man had a stroke, it was over an hour's drive to the nearest city that had a full fledged hospital(btw-a non profit hospital).it is unfortunate, but the hospitals are built where the most concentration of people to be served are, had there been socialized medicine in place, i still doubt they will have built a hospital in the middle of hills and praries. so, regardless of what system is in place, he still suffered permanent effects of his stroke d/t his "geographic location". my beef would be if the man was in his chronic stages of cva and he was denied hospice care because he happened to live in a nursing home, while his neighbor just a building away, lived in an apartment, and he could have hospice care. that is apples to apples. i.e. discriminatory.
you say you have no bias against nationalized healthcare. yes, i do. you obviously do, but for the sake of argument... you contend that your very one-sided position is based on "good common fiscal sense." again, there are pros and cons to every system. one of the cons to your "good common fiscal sense" system is insurance company physicians insurance company physicians. again, you bring another factor into the mix. i have worked in the healthcare system during "fee for service" and the era of "drgs" and now hmos, ppos and the like.yes, it is all geared in one direction: to try to cut the cost of healthcare. the insurance company can not keep running if it is paying out more than what they take in, pure and simple. the fact is that they contract with certain physicians to not run tests, not do procedures, not perform surgery is wrong. it's the same system that forces other physicians to run every test, do every procedure, due to the risk of a malpractice suit. talk about a dicotomy. the insurance company saves money on the contracted physicians, and probably rewards them with the outrageous malpractice insurance premiums it collects from the other physicians. this sounds suspiciously like racketeering in the insurance industy, not the healthcare industry.being rewarded (financially) for denying healthcare to clients... forcing people into bankruptcy, home foreclosure etc. (when they actually have health insurance which they thought covered them.) again, something smells rotten in the insurance industry.probably all their well paid lobbyists at work in dc this hardly seems like "good common fiscal sense." nor does forcing people to stay in jobs they detest (just so they can hang onto their health insurance...i haven't seen anyone in my middle class with fully paid health insurance in many years. most people must pay a portion of their own health insurance-as well they should. paid health insurance perks were a company's way of luring employees to work for them after ww2. it is just that, a "bennie" (benefit) to work for them. people need to apply personal responsibility and know what their healthcare plan covers. all inclusive fee for service coverage is just a memory. which they may discover too late does not cover them anyway) seem likely to yield a vibrant, healthy middle class and economy.
it seems more productive, at least to me, to focus on coming up with solutions rather than angrily criticizing any who try. have you thought of some possible solutions? again, simplification. it scares the hell out of me to think of the federal gov't in the business of health care considering they have done so well with social security, medicare and medicaid. but then again, it's what we have now. think carefully. how long could an insurance company provide coverage when it's taking in less than it is paying out? it's only recourse would be to close it doors or raise the rates. same thing with the federal gov't if it gets into the business of healthcare. only the those that consume healthcare won't incur the expense, the taxpayer will. the big greedy capitalistic business will have long left the country, and the burden will fall on the working class. again.
on the one hand you describe the current system as flawed.for many reasons. the current system actually is impacted largely by insurance industry. when i point that out you retreat slightly,no, i said i have seen it on occasion. saying that nursing home nurses actually do have time to provide one-on-one care, but then throw in the caveat that if they do, other patients in the facility will be neglected. so when i ask whether, in your estimation, nursing home regs and corporate boards are providing adequate staffing your answer is both 'yes' and 'no,' depending on which argument you are pursuing at the moment.i'll try again. staffing levels are just fine, if indeed everything goes fine. assuming there are no falls, no patients having a heart attack or stroke, no residents attempting repeated elopements, no staff calls off, and there are no actively dying patients. granted, no nursing home can staff for what might happen, only according to the day today care of the number of residents in thier home.
you argue that hospice nurses (sw's etc.) have time to spend with pt/fams and that it is a flexible system. true... to some degree anyway. but have you been reading the threads in this forum having to do with case loads ad the fact that many hospice nurses really don't have time to sit with pt/fams? i can only attest to what i have seen. and the fact that they should if their case load is within standard industry guidelines, which if i'm not mistaken runs around 12 per case manager. there may be days or even weeks of higher, but that is not how it is designed. in a perfect world, hospice patients are admitted and they die at a congruent rate. in the real world, we know they do not. like the nursing homes, staffing can not be planned for what might happen. you described some of the details of nursing home documentation. do you suppose hospice nurses do not have to document? according to posters on this forum many hospice nurses are doing their documentation on their own time, after hours, or in their cars (while missing lunch.)yes, i imagine case managers would have those days where they don't get a lunch, and have to complete documentation after hours. it's the nature of the beast. but, if that is standard operating procedure of that hospice, some very poor management is going on.
hospice does indeed have a lot going for it. being a relatively new program its designers took a good hard look at existing systems and then tried to avoid as many of the pitfalls as they could. in other words, they learned from the mistakes that had gone before. they really were quite successful in this, but as one might expect, the business people (as opposed to pure hospice people) became more involved and influential in the evolution of hospice. one of the results of this trend has been the phenomenon of large numbers of marginally appropriate if not flat-out inappropriate hospice pts in nursing homes.only "business" people would admit marginally appropriate patients? the 'pure' hospice people would not admit them, even though their compassionate hearts would think that the patient really needs the services? their hearts don't over rule their heads (and training) to perhaps think that the patient will get worse anyway, we could provide services to ease their "suffering" just a little sooner. i have seen both reasons.
i am willing to concede that there are pts in nursing homes who are appropriate for hospice care. however, there is a very real danger here. i posed the question at the beginning of this post: why are nursing homes so heavily regulated?
there are reasons for all the heavy regulation of course. while i have never worked in a nursing home myself i do not live under a rock. nursing homes have historically been guilty of trying to bilk the system... the government... the taxpayer. now (surprise!) no sooner does hospice become heavily involved with nursing homes than medicare starts gearing up to crack down on hospice. be careful who you associate with. hospice's original designers worked hard to avoid the problems that have long plagued nursing homes. now it looks like hospice has socked that tar baby square in the nose. although you don't live under a rock, you can not be entirely understanding without having "been there, done that" so to speak. nursing homes have an entirely different culture. they even have their own language, ( rugs, "state" therapeutic interchange (translated: this drug is cheaper) mini mental, weekend manager, etc.) nursing home are so heavily regulated because they demand so much documentation because they are so heavily regulated. like i said, it's a game. medicare does not want to pay, so they invent a regulation. nursing homes need to be paid so they design policies for documentation to fullfill the regulation, so they get paid. other nursing homes copy this so they can get paid too. medicare realizes they are paying alot again, to they invent another regulation so they don't have to pay for certain higher reimbursements. nursing homes have to be paid for certain higher reimbursements because they are providing the service so they initiate another policy for documentation of the delivery of service so they get paid. and it goes on and on and on.
our current healthcare system is a shambles. correction. our way of paying for healthcare is in a shambles. millions are under treated or not treated at all. for many reasons, including insurance companies dicatating treatment, people not taking personal responsibility for either paying for their own health insurance and/or not knowing what their coverage is. many who cannot pay actually do receive treatment (often via er) and then those costs are spread to those who do pay (which is why an aspirin costs $20 in the hospital.) exactly why i said the way we pay for our health insurance is in a shambles. in this way, a lot of the money exchanging hands in the healthcare system is carried out under the table... and with that as a system (actually more of a non-system really) there are lots of shenanigans going on (cost-spreading, denying coverage to paying customers,those reasons involve insurance companies inappropriate hospice admissions combination of reasons stated aboveetc.) why not put the money on top of the table... where we can all see it? why not pay for what pts need instead of enriching slight-of-hand insurance company executives while denying care to pts.here is where we agree!!!!
one cannot make constructive change without first becoming aware of what is going on now... and unfortunately, becoming aware of what is going on now invariably involves an uncomfortable degree of honest self-evaluation. you (onethunder) seem wholly unwilling to conduct an honest evaluation of the nursing home industry. you are unwilling to concede to anyone who has actually worked in a nursing home and might really know the ins and outs, not just the sensational headlines you read in the media. you talk out of both sides of your mouth saying things like... nursing homes are adequately staffed, but then only if nurses neglect some patients...if one goes back and re reads the context in which this was qualified, one can see that you border on name calling, another old debate club trick. or no one has a right to healthcare, but nursing home pts have a right to hospice carenusing home residents have a right to hospice care if the same care is delivered to a comparable patient in their home. we need to stay on track here with the apples and oranges thing. . you adamantly defend nursing homes (even while hinting at their obvious weaknesses) nothing is perfect. for the most part, they do the best they can with what they have. and simultaneously (angrily)really? angrily? i think you are over dramatizing here. insist that any system other than the current one would only be worse. in reality, i insist any other system that removes the personal responsibility of an individual, pays for their healthcare on the backs of the taxpayers, and fosters dependence on the federal govt, who should not be in the business of healthcare, or any other business but what is stated in the constitution, would only be worse.
i suggested that if we accept your (onethunder) contention that nursing home pts have a right to hospice care then it would be logical to assume that all dying pts have the same right (lest we discriminate.)) for example, when a child comes into er and dies unexpectedly (for whatever reason) should that family be penalized for not being aware their child was about to die? should that family be denied a year's worth of bereavement counseling? again, i have to instruct: qualifications for hospice is a terminal diagnosis. two physicians must agree the patient has 6 months or less if the disease takes it's natural course, and the patient/family elects to have hospice care. your senerio is so far off it's ludicrous. if, as i said, we accept the concept of providing care evenly across the board, then hospice will have to be re-tooled... if not entirely re-designed.
rather than insisting that the current (broken) healthcare system is our only hope, how about considering other options... how about nursing homes considering a hospice-like model for example? they are. some are trying palliative care programs. the crux of the matter is, they can not provide all the services of hospice. chaplain, 13 months of bereavement,etc without getting reimbursed for it. as of now, they do not get reimbursed "extra" for the palliative services. so, despite good intentions, the care can not hope to match hospice services, and it is foisted on an already stretched to the limit staff. if it works for us, why not for you? of course it would be difficult to determine just what sort of per diem/capitation system would suffice for a nursing home when the waters are already muddied by the presence of a second provider, but it's something to think about.
how about it onethunder? any suggestions? you argue that unevenly applied healthcare is discriminatory while at the same time angrily defending systems that are woefully and blatantly fragmentary and discriminatory. you are opposed to government "playing god," but favor the current system which pays insurance company docs bonuses for digging up ways to deny care? see above comments
i have literally spent hours sitting in an er waiting to be seen, wincing in pain the whole time.hours compared to weeks/months for a socialized medicine patient to have a bypass or a hip replacement is not a fair comparison. to the other patients. i worked in er for many years and am fully aware of how long pts are frequently forced to wait. no doubt some canadians have had similar experiences.multiplied many times over. to one degree or another that is simply the nature of the beast.agreed. your hospital can't staff for what might happen. just an "average". the difference between me and a canadian however is that while he is sitting there fretting over his illness, he does not also have to worry about losing his home.no, there is a good possibility he could die waiting for his surgery.
michael

the big difference between how you and i see things is two fold. i want to see the health care system we have improved one bite at a time. you would like to throw out the whole meal and start over.

i want to see our healthcare funded by limited gov't programs and more personal responsiblity. you want comprehensive healthcare to be an entitlement.

we both agree that the insurance companies have some pretty shady practices, if not down right illegal and immoral. hhhmm perhaps we should join forces and elicit change on the thing we agree on?

AnabelRN · Jan 5, 2008

Oh, my gosh this is happening to my hospice too! The Medicare probe, I mean. I haven't had time yet to read all of the responses to this thread but what an eye opener this is! I work for a non-profit agency. Our census has dropped from over 200 in the beginning of last year to just under 80 right now. Our executive director as well as the woman below her have left. Seems like almost everyone else in the agency has cut their hours to part time. My manager told me this week that "rumor has it" that my position (weekday on call) will be eliminated by next week. :angryfire She's an idiot. Anyway, I'm so glad I found this site! Our unfortunate situation has always been advertised to us by the powers that be as sort of a "poor us, what did we do to deserve to be all but cut off from Medicare" and now I realize (duh) that it was the agency's mismanagement and not following clearly outlined Medicare rules that got us in trouble. Those money hungry a-hole b%$#&*ds are about to cost me my job!