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If you could change medicare/medicaid...

Posted

Specializes in Peds(PICU, NICU float), PDN, ICU.

Ok, so I've thought about this in all the years I've done this job. Then I started wondering about what others think. Finally, I thought maybe the decision makers might run across this thread one day.

So, how would you change things if you could?

I'll start. I think the way the equipment and supply system works, really doesn't work. How is it that insurance will supply 50 bottles of peroxide, but only 12 trach ties in a month? Wouldn't it make more sense to give each family a certain amount to spend each month? Then the families could have the 30 ties they need instead of reusing nasty ties. And they wouldn't be getting 50 bottles of peroxide a month that they don't use anyway.

Another issue is nursing. I think it would be better if there were a database of nurses and patients/parents. Like a matchmaking service, where nurses and families find each other based on availability, nursing skills, education, pet friendly, smoker/nonsmoker, etc. The state runs the site and provides RNs/case managers to oversee the cases. No more agencies. Private scheduling makes families happier. And even an area in the database for last minute nurses to cover call outs for families and to supplement the nurse that has a pt in the hospital. Wider selection of nurses for the families and better chance of cases closer to home for nurses. The state could pay us more per hour and still save money because they wouldn't be paying so much to the agencies. Even better if we got state benefits out of it. The states want to save on their budget and I think they could save by doing this. And we could get paid what we deserve.

I think better rules should be in place for pt/family boundaries as well. We are nurses, not babysitters and not maids.

I think the foster program for medically fragile children could be improved. Instead of the kids being in homes where the parent is barely trained, the state should consider nurses first. This again would save the state money and provide better care for the children. Nurses could work from home, minimizing expenses for the state because of the cost of a facility.

The state could also open a few medically fragile daycares. The state would save because each nurse could have 2 or 3 total care patients each. Some parents just want care while they are at work and want to do the rest themselves. Plus the kids that are capable, could learn socialization skills and interact with others like them without fear of judgment or bullying.

Any other ideas, thoughts?

duskyjewel

Specializes in hospice.

I think Medicare, if we must have it, should be turned into a tax credit program and individuals allowed to shop and compare and buy coverage that is right for them. And Medicaid should be block-granted to states so they can design their own programs that fit their populations and needs best.

SDALPN

Specializes in Peds(PICU, NICU float), PDN, ICU.

I think Medicare, if we must have it, should be turned into a tax credit program and individuals allowed to shop and compare and buy coverage that is right for them. And Medicaid should be block-granted to states so they can design their own programs that fit their populations and needs best.

I'm talking about PDN related, that's why I posted it in the PDN section. Not the rest of the program.

duskyjewel

Specializes in hospice.

Sorry. *Ducks out*

middleagednurse

Specializes in nurseline,med surg, PD. Has 50+ years experience.

I completely agree with SDA. M y client goes to school, coughs constantly, and gets 3 trach covers a day. By noon she has used her 3 and Im using the plastic "skeletons. Not healthy."

brillohead, ADN, RN

Specializes in Cardio-Pulmonary; Med-Surg; Private Duty. Has 5 years experience.

How in the heck do you get 50 bottles of H2O2 per month? One of my patients gets TWO tiny 12-oz bottles of peroxide per month, which is supposed to do a 50/50 (with water) soak of the inner cannula twice a day. (Did I mention it's the inner DISPOSABLE cannula that we're disinfecting and reusing for a week or more at a time? *sigh*) That means we have 11.8mL of peroxide provided per soak.... yeah, right!

And you're grossed out by twelve trach ties per month? That client gets his changed twice a week.

We have diapers coming out of our butts (no pun intended) because he's a super-pee-er and gets double-diapered every time to try to contain the flooding. But we have trouble getting enough of the diaper liners (huge maxipads, basically) to go into the diapers to try to soak up some of the deluge.

But we have boxes and boxes of HMEs for the trach (what I think middleagednurse is calling trach covers?) stacked up everywhere.

And for the love of all that is holy, would it kill them to provide enough wipes??? I think we end up with three wipes per day. What the heck????? How are we supposed to maintain skin integrity if we can't even adequately cleanse the diaper region? Three wipes/day wouldn't be enough for a tiny little 7-pound newborn, let alone the 130-160 pound patients that I have!

One family has a spray bottle and a roll of paper towels for BMs -- you try to hose off as much of the solids as you can with the spray bottle and then wipe with the paper towel. But they don't even always have the paper towels, so I tear the wipes into thirds and the paper towels into fourths (and that's the select-a-size strip of paper towel, not a full square) to try to make them stretch further. My other family fortunately buys full cases of baby wipes to supplement the tissue-paper-thin "adult wipes" that they get.

Those adult-size wipes tick me off, too, because they are so wasteful. You really don't need more wipe area than the size of your hand, because once you get the hand-portion all poopy, you're not going to go back and rewipe with the still-clean corners/edges. That's why I rip them into thirds before using them, so I at least get to use all of the surface area of each precious, rare wipe.

And how are we supposed to maintain skin integrity without powder and/or barrier creams in a diapered individual?

Yeah, I see a LOT of room for improvement in the DME sector. I have no clue how the orders are actually figured up, but it's obvious that supplies are NOT a one-size-fits-all situation, and there needs to be some way to customize the things coming into the house according to the actual needs of the patient.

As for staffing, I love the idea of a "matchmaking" internet service with nurses being direct state employees rather than working through agencies. The only problem with that is it would put an end to working more than 40 hours/week, if you want to do that. The state won't want to pay OT rates, and with agencies out of the picture, you won't be able to work for two different employers to get over 40 hours/week. (I'm currently working 66-80+ hours/week through three different agencies to knock out some debt before going back to school for my BSN.) Then again, if we weren't having to cover the cost of the agency's rent, utilities, manager, RN case manager/supervisor, and secretary/scheduler, we might be paid enough that we wouldn't NEED to work 2-3 jobs to bring in adequate income.

I'd also like to see some strict adherence to guidelines for what patients need/deserve nursing coverage. My current patients all have high enough needs that nursing is appropriate -- trach/GT/seizure precautions/total care for one, trach/vent/quad for another. But seeing posts here about 12-24-hour care for kids who just have a GT, no vent, no trach? How on earth is this an appropriate use of healthcare funds?

In the meantime, my trach/vent/quad who needs Q4H straight cathing and Q2H repositioning often went without overnight care because they couldn't find enough nurses to cover the case. Maybe if there weren't a bunch of nurses babysitting GT kids who don't need nursing care, there would be enough nurses for the high-complexity cases?

Phew, I feel better.... gotta love a good rant! LOL

smartnurse1982

Has 7 years experience.

!

Maybe if there weren't a bunch of nurses babysitting GT kids who don't need nursing care, there would be enough nurses for the high-complexity cases?

Phew, I feel better.... gotta love a good rant! LOL

You are assuming that the nurses who work basic cases would work on trach/vent cases.

I know lots of basic nurses who do not want to work with vents at my agency,and it is a sizable number of nurses who do not work with high tech cases.

I really do not blame them,as they get paid the same amount per hr as the nurses who work high tech cases.

Why work harder making the same amount of money for something easier?

smartnurse1982

Has 7 years experience.

To add,i have never heard of Pdn clients receiving Medicare..

Do they?

I know in Ltc that Medicaid pays for most of the long term residents who have exhausted their funds.

Medicare not so much unless someone was only there for short term rehab.

brillohead, ADN, RN

Specializes in Cardio-Pulmonary; Med-Surg; Private Duty. Has 5 years experience.

You are assuming that the nurses who work basic cases would work on trach/vent cases.

I know lots of basic nurses who do not want to work with vents at my agency,and it is a sizable number of nurses who do not work with high tech cases.

I really do not blame them,as they get paid the same amount per hr as the nurses who work high tech cases.

Why work harder making the same amount of money for something easier?

My question is, why do stable kids with *just* a GT get state-paid nursing coverage in the first place?

SDALPN

Specializes in Peds(PICU, NICU float), PDN, ICU.

Some of them have other conditions that require hours.

Some have seizures and desat, but aren't quite ready for a trach or don't need one. They may require lots of meds that don't allow the parent to get any rest.

Some may have severe respiratory issues that require suction and a nurse to monitor/assess. Some of those kids end up getting trached down the road.

Some have conditions that require close monitoring of labs, I&O, etc.

There are reasons. If the kid is healthy besides needing to eat in a different way, they won't get nursing. They may get an aide if they are lucky.

brillohead, ADN, RN

Specializes in Cardio-Pulmonary; Med-Surg; Private Duty. Has 5 years experience.

Some of them have other conditions that require hours.

Some have seizures and desat, but aren't quite ready for a trach or don't need one. They may require lots of meds that don't allow the parent to get any rest.

Some may have severe respiratory issues that require suction and a nurse to monitor/assess. Some of those kids end up getting trached down the road.

Some have conditions that require close monitoring of labs, I&O, etc.

There are reasons. If the kid is healthy besides needing to eat in a different way, they won't get nursing. They may get an aide if they are lucky.

I specifically remember someone posting here that they didn't understand how their patient had approval for nursing hours, b/c all the kid had was a GT and he/she was perfectly healthy in every other way.

SDALPN

Specializes in Peds(PICU, NICU float), PDN, ICU.

Yeah, that doesn't make sense. I've seen those cases. There are parents that manipulate the system to get free child care. There needs to be checks in place for that.

LadyFree28, BSN, RN

Specializes in Pediatrics, Rehab, Trauma. Has 10 years experience.

You are assuming that the nurses who work basic cases would work on trach/vent cases.

I know lots of basic nurses who do not want to work with vents at my agency,and it is a sizable number of nurses who do not work with high tech cases.

I really do not blame them,as they get paid the same amount per hr as the nurses who work high tech cases.

Why work harder making the same amount of money for something easier?

I got paid MORE as a trach/vent nurse; I enjoyed the complexity, as well as the increase in pay.

We are in the same area from previous threads.

There are too many agencies in your area that pay more. :no:

I also negotiated more at certain places my rate for complex cases as well.

To answer the question of the thread, I would change the policy that nurses would be paid closer to the amount that is allotted for nursing; most agencies do the 60/40 split, instead of giving the full amount to nurses; across the board it would be illegal to pay nurses less than the funded amount; I would also makes sure DME were tailored to what the pt needs, as well as have emergency supply prorated for a minimum fee.

SDALPN

Specializes in Peds(PICU, NICU float), PDN, ICU.

How would the agencies make money if they don't pay less than the funded amount? If they are getting $40/hr for a case, they can't pay us $40/hr or they wouldn't stay in business. But I'm sure they could afford to pay us more if they weren't so greedy. That's why I think they should take the middleman out. Both the nurses and the gov come out better. And the families have more choices.

LadyFree28, BSN, RN

Specializes in Pediatrics, Rehab, Trauma. Has 10 years experience.

How would the agencies make money if they don't pay less than the funded amount? If they are getting $40/hr for a case, they can't pay us $40/hr or they wouldn't stay in business. But I'm sure they could afford to pay us more if they weren't so greedy. That's why I think they should take the middleman out. Both the nurses and the gov come out better. And the families have more choices.

They still get funding for operations; they get an approved monetary amount for the child as well; most of the time these agencies are scooping up nursing money and patient money.

I'm hesitant about removing the middleman, meaning that alloyed money for diagnosis would be left to the parents; meaning, they would take the money and not be able to pay us. :no:

I rather deal with CMS directly. :blink:

Edited by LadyFree28

SDALPN

Specializes in Peds(PICU, NICU float), PDN, ICU.

I've never seem that in the paperwork. I've only seen a specific number per hour paid. Maybe it's different in different states? Do they leave that other amount off the paperwork where the state says what they pay?

LadyFree28, BSN, RN

Specializes in Pediatrics, Rehab, Trauma. Has 10 years experience.

I've never seem that in the paperwork. I've only seen a specific number per hour paid. Maybe it's different in different states? Do they leave that other amount off the paperwork where the state says what they pay?

CMS has specific funding and prices related to reimbursement for payment through diagnosis; they have separate reimbursement for DME, and they bill separately for nursing, HHA, nurse visits, and even provider visits.

Once the agency accepts a pt; CMS (federal or state, and insurance companies usually follow CMS guidelines with some adjustments but very little difference) bills the company directly based on pt diagnosis, then pays them directly for nursing staff, and approves the hours; they pay the amount monthly, do agencies can make enough to cover operations in terms of the amount of cases they have, per office; if they have 500 cases per office (including home visits) and have 20 offices, they can make a nice profit.

Most home care agencies I worked for had Peds, Adults, and Skilled visits; they get enough money to cover operations, lol.

I also worked at a medical daycare; they would get 300-500 dollars per child, depending on their specific diagnosis; the more acute, the better; however, if the child didn't show up, they couldn't get paid.

SDALPN

Specializes in Peds(PICU, NICU float), PDN, ICU.

CMS has specific funding and prices related to reimbursement for payment through diagnosis; they have separate reimbursement for DME, and they bill separately for nursing, HHA, nurse visits, and even provider visits.

Once the agency accepts a pt; CMS (federal or state, and insurance companies usually follow CMS guidelines with some adjustments but very little difference) bills the company directly based on pt diagnosis, then pays them directly for nursing staff, and approves the hours; they pay the amount monthly, do agencies can make enough to cover operations in terms of the amount of cases they have, per office; if they have 500 cases per office (including home visits) and have 20 offices, they can make a nice profit.

Most home care agencies I worked for had Peds, Adults, and Skilled visits; they get enough money to cover operations, lol.

I also worked at a medical daycare; they would get 300-500 dollars per child, depending on their specific diagnosis; the more acute, the better; however, if the child didn't show up, they couldn't get paid.

Exactly but I've never seen a separate fee for operations, just a rate for hourly nursing which covers nurses and operations.