Published Feb 23, 2002
We are having a major crisis in our supply cabinet, as in it is empty 99% of the time!
Part of the problem is that nurses do not charge properly for supplies. The supervisors try to police supplies, but it isn't always possible. This week I had to change a foley on a new pt, and we knew it was due, but supplies would not arrive for about 5 days since weekend involved. I went to closet to get a 16Fr foley cath, NONE in the closet, no caths no tray, no nothing. Sup tells me to call nurses and see if anyone has supplies in their cars. Like I have time, or they have time, to waste like that! 20 minutes later I did find a nurse who had a cath, hospice gave me a tray, and we had bags. This is sooo frustrating.
I admit supplies are a weakness for me, never having been a FT CM, I am getting all befuddled as to how much Medicaid allows and the PPS budgeting of supplies, etc. I made a costly boo-boo this week, I ordered for a MS pt a 20Fr 30cc foley, obviously the tray comes separate, but I missed that it said 10cc syringes, I guess I assumed that if I order a 30cc foley, I need 30cc syringe in the kit, didn't think I had to specifically write it in. Problem is, it's a managed care co, so now I have to beg for auth and forgiveness. The supply co was wonderful and agreed to exchange the incorrect items. It is so frustrating, that simple and stupid mistake cost me 45 minutes of time today with phone callls back and forth to DME, pt, and supervisor.
We are having a big problem with supplies for new admits in managed cares. How do you guys get reimbursed for supplies from your stock if the managed care co doesn't use your dme company? Ex we use a co called Sterling, they have a great rep, and we order all medicare supplies from them, but the blues do not contract with sterling, they use several other dme co's, so were "not allowed" to take supplies form cabinet for managed cares, well how the hell can you do wound care if the family was not given a small amount of supplies from the hospital?? So, we made them , the managed care co's, promise to reimburse an amount equal to or less than $100 worth of start-up supplies from our stock closet, they said the would, but now there is some new complication or catch 22, and they actually do not pay. This has put us under (over the course of a few months, and we now have no 4x4's, saline, forget duoderms, etc in the closet. Families are angry that we don't have necessary supplies etc. I give them the supply supervisors number, and let her deal with it, but it is very difficult to provide the needed care in this crisis.
So, how are other agencies handling start-up supply reimbursement from managed care co's?? Instead of just B*tching, I would like to research how other agencies are working through these issues and try to offer a few solutions. Thanks for any help!
NRSKarenRN, BSN, RN
"How do you guys get reimbursed for supplies from your stock if the managed care co doesn't use your dme company? "
Simple....We Don't get reimbursed.
What to do:
Rx for supplies needs to be ordered like this on PCP's prescription pad:
1. Diagnosis and co-morbidites that would explain supply need
2. Type of supplies and specific instruction for use.
3. Frequency of refills.
4. DME for canes, walkers, wheelhairs need height, wt; if over 250 lbs need hip measurement--include rational for removable arms or need forfoot rests. eg. paralysis dominent side( R or L), dependent edema, foot drop etc.
If on insulin, include frequency of testing esp QID to get correct # of teststrips and lancets
DX: New onset IDDM with DKA and peripheral neuropathy
Needs setup- equipment: glucometer with memory, lancet device, 200 lancets and 200 test strips
Pt to test BS QID and prn.
Refill X 4.
Rational for glucometer with memory is that patient is forgetful: this will allow PCP to track blood sugars.
Guidlines for diabetic supplies:
NIDDM- 50 lancets and test strips/month (1x day and PRN)
IDDM- 100 lancets and test strips/month (2x day & PRN)
Juvinile, difficult to control, insulin pump---document why more supplies needed.
Legally BLIND eligible for talking glucometer.
Dx: Permanent Urinary incontinece with frequent blockages
Dispense 2-16 fr 10 cc Silastic catheters, 2 insertion trays , 2 bedside drainage bags and one catheter strap/month. I irrigation tray prn.
Change Foley catheter q 2weeks and prn. Irrigate with 50cc NSS prn.
Rationale: Irrigation tray only reimbursable if PRN and not routine per Medicare. Frequent blockages will cover 2x month change as standard is one cath + equip/month.
( Medicare patients must have wound measurements + characteristics up front, now bundeled into cost of SNV).
Dx: Cellulitis BLE- 6 open wounds on ft and leg. IDDM.
Apply NSS wet-dry dsg, cover with abd pad, kling and secure with tape. Cover with 4in Ace wrap (2 per leg) toe to knee Daily.
Dispense 200 4x4's, 60 kling, 30 abd pads, Four 4in Ace wrap, 2 rolls 1in paper tape.
Rationale: Both legs need dressings with multiple open sites, two kling per leg , 2 abd per leg, 2 Ace per leg.---2 week supplies.
Best to order only 2 weeks of wd supplies as allows for wd orders to change esp if frequent rehospitalizations.
MC quidelines: 3 duoderm or Tegrederm per week per open area. DSD not to be used for cleaning. Tegrederm not to be used to secure dressings, may be used as packing.
As part of admission process, I routinely explain to hospitals takes 3 days get supplies delivered these days. SEND WD SUPPLIES home. Several hospitals send me RX automatically.
I also request RX upfront especially for medical assistance patients, and those coming from inner city teaching hospitals--- and spell out to them what RX needs to have as above. That way when nurses get to home should have supplies. If I know upfront supply difficult to get/special order, I will set up delivery with RX from hospital thru DME company that I know delivers to patients area.
Get to know what suppliers your insurance companies will utilize and only order from those places in order to get it covered for HMO clients.
When we get non-routine insurance clients, part of our intake process is to inquire which DME is covered.
Hope this helps.
hoolahan, ASN, RN
Thanks Karen, if only all intake nurses were like you. It's usually like you said when we get the pt from a Liason hospital, or the rehab, but when MD's call in referrals, half the time we don't even get an accurate diagnosis, let alone being told there is a decub, or that we will even need supplies. Or if we get the referral from a non-local hospital.
Still wondering if anyone else has a system that works. There are days I go to the stock closet and there is not 1 4x4 in there. I am not sure what the probelm is, but it is getting old!
Hi hoolahan. I think Karen gave a very thorough and excellent outline for managing your supplies. It's really hard if you don't do home health full time. One of the agencies I worked for had regular staff to coordinate supplies. One of the LPNs was used to do part time intake and coordinate the supplies and she had stickers on all the supplies that we removed and placed on the patient supply chart when we checked out anything for the patient. She became very knowledgeable about billing which resulted in fewer denials of services and anything related to the visits. She also made friends with some of the insurance case managers. Is your supervisor aware of this problem?
I'm not close to being an expert on informatics, but I wonder if a bar code system would work if it was set up in a effective but user friendly manner. It would probably entail alot of cost up front for an agency, but would possibly result in significant savings on down the road. With the bar code system, it could be possible to track who, when, where, and what of every supply that left that closet. All sorts of things could probably be tracked if supplies and equipment where automated. The best part of it would be is that if the system worked really well, the patient and the nurse would hopefully experience very few delays in care.
As far as intake is concerned, I don't know why the necessary information from the patient chart can't automatically be forwarded to the office. Most helpful would be a copy of the patient's admission face sheet if the patient is discharged from the hospital, an H&P, any records of relevant labs, tests, and op reports, the discharge summary and discharge orders.
This is the typical oder faxed on RX blank form I see daily:
Patient Name, " VN for homecare" and doctors signature.
THAT"S ALL even if BID wd care is needed, GRRR....many intake RN's call and get clearer orders, but some feel that's enough info for an RN to do an Eval...sigh.
That is exactly the kind of referrals I see. Or, md office calls our intake dept, and the intake nurse is ON THE PHONE with the office and doesn't ask for an emergency number, or what the allergies are. I got one of those the other day, went out to see pt, he knew he had allergies, but couldn't remember what they are, of course it was the weekend, so I couldn't reach anyone who had access to his chart, and he had not been in any hospitals recently.
I discussed this in a staff meeting the other day, and I asked why these type of referrals can't wait until Monday to open, so we can reach the office. I think I'm going to start to refuse to open cases like that. Maybe that is the only way we will get the intake dept to do their job. They hand us back forms all the time asking for more info, it should work both ways.
And while I'm on the subject of MD referrals, do you guys find that docs refer so pt's can get labs done?? I have a pt who was rereferred and this will mean another round of weekly PT/INR's. Last time in 6 weeks, he doc was not aggressive enough in making changes, and I felt like I was out there wasting my time. She went back into the hospital with a CVA, though I am questioning that diagnosis, b/c there is no change in her status from then to now, and she had none of the typical symptoms of CVA. She had gotten dizzy, lost her balance and fell...again. Yet, once again, her doc won't even order anything for the diziness, like meclazine. How many times does this have to happen?? Anyway, last time it got to the point where she was getting her hair done and asked me to work the labs around that. Bye Bye!! I said, if you can have your paid personal assitant drive you to the hairdressers, you can go to the lab, she says, "But it is so inconvenient!" The very thought of this pt again is so annoying, I just d/c her about a week before. I have asked her doctor to be more aggressive w meds and try meds for diziness, but he didn't listen, what does a nurse know? Grrrrr. Thanks for letting me vent. If I had been the one to open the case, I would have been an open and shut nurse eval, no change and bye-bye!
glad to have you out there stomping for us hollahan. i have received referrals with incomplete diagnosis, allergies not addressed. even the wrong address, so i'm standing on the street looking silly. have even gone to client's home to work even before anyone has been out to officially open the case, no chart, just a referral in my hand
Hey, Hoolahan and NUR20--it sounds like we all work for the same agency!!!! VENT AWAY!!
I guess I don't feel so bad now!
NurseDennie, BSN, RN
Sheesh you guys! I can understand if you get a patient direct from a doc but there's no excuse for a hospital sending you a patient without the proper orders and supplies. I worked on neuro floor and I always considered my D/C and/or transfer instructions to be the working orders for intake for the HH nurse.
We had incredible social workers who really taught us EXACTLY what we needed to say and how we needed to say it so that stuff was as seamless as possible. That justification for the big-boy BSC and W/C should have been done on the D/C sheet from the floor nurse. When it's done there, it takes - what? 10 seconds?? Also, how difficult is it to send home some wound care supplies, etc. (although I can see how the bean-counters at the hospital would disagree)
Maybe there is someone who could educate the social workers in the hospitals that are causing problems. It was definitely the social workers who gave us the instruction that we needed.
Hi. I know the information that I would like to have to start patient care was a dream, but it really should be reality. NurseDennie, my hat's off to you on your conscientiousness in hospital d/c planning. Unfortunately, that's an exception. As you're well aware, there's a major disconnect between the doctor's office, the hospital, if applicable, and the HHA as far as patient care coordination is concerned. On top of that I don't think that many people in management understand this. Or, they are too overwhelmed to do anything about it.
IMO, when I was in nursing school, I don't feel that the importance of nurses connecting the dots beyond their immediate work setting was emphasized. In fact, I don't remember the term integrated health care used in my early days of nursing. That came along much later. The process of comprehensive patient care coordination really didn't become emphasized until after managed care became a household word. The beauty of having worked in a hospital setting and then going into a home care setting is that you get a much bigger picture of what patient care is all about. You began to understand why certain processes need to take place before you can experience a measure of success with improvement in the patient's condition. You also get frustrated as a home care nurse because you know how to better connect dots, but you don't get the proper support.
Managed care was supposed to force us to change our habits with the provision of services. All I feel it's done is aggravated the problem. Before the BBA or OPPS for home care, we had adequate supplies. Now, you just about have to go buy some to take care of your patient. It doesn't seem to be a happy medium.
Karen, hoolahan, I'm ready to get that universal CPR (computerized patient record) system started right away. I agree with NurseDennie, it does not make sense for the hospital to provide us with poor quality information for patient care. It really doesn't make sense for the doctor's office to not give us all the support they can. Of course, if the home health nurse does not have all the tools to make a half way decent impact on the patient's home adaptation then guess what? You got it, they recycle back to the hospital. Managed care, IMO, has done nothing to change die hard habits in the health care delivery system.
NurseDennie, I have to tell you, I've encountered almost as many sloppy nurse d/c planners as social workers.
Mijourney, I have had good and bad. We have Liasons from our agency in the major hospitals and a trip weekly to the rehab. If a pt known to us is in a rehab, Liason's will also go. Trouble is, in the hospitals, the nurses need to realize that the managed care co leave sus w no supplies. I think the nurses on the floors, speaking from my own experience before home health opened my eyes, just do not realize what will be needed. Pt's get a day or two worth of supplies, but that's on a Thursday, and we run out on weekend, Heaven forbid we get auth on a weekend.
I know my agency won't put out for CPR system. WE really really can't afford any extras right now. If we could I vote for a recruiting bonus to bring us some more help!
Hoolahan, we both have been there and done that. We know that hospital based nurses do not receive the education and support they need to understand what is needed for patient care in all scenarios. What's worse they frequently do not have the time to focus on patient care activities beyond the immediate. Practicing solely under the medical model does not lend itself to a comprehensive view of patient or family care.
Until the model of practice for patient care or the health care delivery system is changed, we will continue to experience a conflict over the resources needed for direct patient care. I agree there are some good d/c planners or liaisons out there, but they can only do so much within the system. The rest is left up to active patient and family participation and the physicians and their staff as well as those of us who have a good idea on how to connect those dots.
The situation with supplies is just as drastic in many hospitals as it is with many home health agencies. Remember PPS, which resulted in dramatic changes in the billing and payment structure, was started in the institutions and within the last five years have been applied to the ambulatory setting, LTC, home and community health. Also keep in mind that when OPPS was started, that the government stepped up fraud and abuse programs in Medicare and Medicaid. This combination of strategies has had a negative impact on the practices of many a nurse, physician, and therapist. We have not been able to keep up with the changes in rules and regs and the advancing of technology. It has particularly affected our patients who usually do not understand very much about the complexities of medical and health care.
I think that Karen really offered some of the best solutions to your supply problem. The majority of supplies in a home health agency are routine supplies. That means that there should be a continuous stock of these supplies or otherwise I would wonder if there may be an internal problem. If there are special supplies needed, then I would guess that's where your liaison would come in, even on a Friday afternoon. I agree with you that it would be helpful if the hospital nurses could see to it that the patients are also covered through more than a couple of days, but as I indicated earlier, I don't see that happening anytime in the near future. What would really be phenomenal is that communication between the liaisons, the doctors, the patients and families be in perfect sync so that the patient and home health staff could start out on the right foot for maximum home adaptation.
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