7/30 This week, I learned Deanna Troi sucks

nutella, MSN, RN · Jul 30, 2016

I agree that there is some amount of burnout, frustration ,discouragement, and hopelessness generally speaking in healthcare and more so in nursing.

I learned this week that the above is a result of time constraints, excessive regulations, reimbursement changes, and short staffing. The reality between expectations of productivity and actual facts can be concerning. For example: "Slower and intuitive thinking is often more effective than mental agility" .

And :

Optimizing performance does NOT happen through increased productivity but through fruitfulness.

This comes straight from the textbook Quantum Leadership chapter 13 by Porter-O'Grady & Malloch (2015).

So what to do with the above thoughts and knowledge? Nursing care needs to be overhauled to ensure that nurses can actually do the value-based high quality patient-centered care everybody is asking for. It is a great idea but when a nurse has too many patients or /and a CNA that does have too many patients or MIA the nurse cannot achieve that. Instead, the nurse continues to run from task to task without time for reflection, thinking, or critical review of the bigger picture. And that employers see nurses and CNA mostly as productivity slaves that have no choice because economy is "bad" and nurses need jobs to make a living is unacceptable.

I learned that a low carb diet results in less endurance when working out and that headaches can be part of the adjustment.

Also, when you are on a low carb diet, the trip to the supermarket is mostly "Oh no - can't get that either - full of carbs". Changing a life style to low carb and counting carbs is not easy.

I learned that there is an ongoing confusion about hospice care in the hospital and the general inpatient benefit. Basically what seems to happen is that if a patient is in the hospital and elects to be CMO but is not imminently dying, the CM often ask for hospice to come out and evaluate if the patient meets criteria for the Medicare General In Patient benefit for hospice care. The CM often thinks of it as a cost reduction method - but that is not the way it is intended or should be used! GIP is for patients who are signed up for hospice care and who have so severe symptoms that they can only be managed through an inpatient stay. If that is the case, the options are usually hospice house or hospital or GIP care in a contracted nursing facility that has 24/7 direct RN care at the bedside. But - Medicare clearly states that this is short term and once symptoms are under control, the patient does not meet criteria for GIP and is only "routine hospice level of care".

What that means is this :

If a patient is in the hospital , becomes CMO and the CM says - well , just sign up for hospice and if you qualify for GIP you can die in the acute care hospital. Not really. If a patient is imminently dying or truly GIP they stay in the hospital but if they are not imminent (die within 24-48 hours) they need to be moved to a different setting. That can result in costs for room and board if the patient is not going home with home hospice.

Let's say a patient wants to go to the hospice house. The hospice evaluates the patient and says 'you qualify for GIP, we take you if you want to come here". The patient transfers. On day 1,2 and 3 the patient is very symptomatic and requires GIP level of care - Medicare pays. Now comes day 4 and the symptoms are under control, no need for change in dosing or anything - now the patient is routine level of care and Medicare won't pay for room and board. Lets say this happens at the 5 as well and on day 6 patient is GIP again. This will generate a bill because the days that the patient was not GIP appropriate but stayed in the hospice house, room and board will have to be paid for - it is usually several hundreds per day of routine hospice.

If a patient goes to a nursing home with hospice same deal. Now - if a patient also has Medicaid, medicaid will usually pick up room and board and medicare will pay for hospice. So basically, if you have low income and qualify for medicaid, you can go to a nursing home with hospice and it is paid for. If you have assets and not Medicaid the expectation is that the person uses some of their money for their care.

And - of course a patient of HCP has to agree to a hospice admission. Let's say the patient is in the hospital and is now CMO. The CM calls hospice to come out but is not clear about it with the patient or family. Hospice comes and finds that the patient is hospice appropriate and for that day GIP (because that is a day by day decision, you can not be GIP for the next week from the get go) and would like to admit the patient. But the patient or family do not want to sign up to hospice. The patient is still CMO and the CM now has to figure out what to do because the acute care hospital does not get reimbursed the usual rate for somebody who is CMO - is results in a loss of income so to speak.

What a lot of hospital staff forgets is this : The reason you should ask for a hospice to come in to admit a patient GIP is not to "save money" but to get expert level of care for a patient who is and the end of life and so symptomatic that expert advice would be in the best interest of the patient. Or you want to establish a relationship between hospice and patient/family. If a patient is in the hospital and accepts a GIP admission and signs on to hospice while in the acute care facility something happens:

Now the patient elected the Medicare Hospice benefit and is under the care of the hospice!!! That means that the hospice agency directs the care plan! The patient is still in the hospital, has nurses and physicians. The physicians order medications and such but the care plan come from hospice and hospice comes in daily (hospice RN) to assess the patient and manage their symptoms. They make daily recommendations for medications and the hospice medical director talks to the hospice nurse who puts the recommendations in writing.

Now the hospital has to take the recommendations and implement them! After all, the patient needs hospice expertise. They also have the spiritual coordinator, social worker and other staff involved. The hospital gets paid by the hospice agency now. I hope you guys see the problem with this arrangement: care coordination. Hospital physicians usually do not know that there are recommendations, nurses often do not know how GIP works because it is not that common.

http://www.nhpco.org/sites/default/files/public/regulatory/GIP_Tip_GIP_Sheet.pdf

If you made it until here you deserve a gold star! Are you more confused now? if yes - that is how it is for most nurses and even hospice staff has a hard time to understand this fully. There are many more small details that make it really chaotic.

For example : Longterm care facilities are very well versed to provide routine level of hospice care but most can not provide GIP level of care. Often because they do not have 24/7 RN coverage for that patient. And no - having a RN nursing director in the same building does not count, it has to be the assigned direct bedside nurse. And also no - it is acceptable to have an LPN cover the patient who is GIP level of care even if it is "only from 3 am to 7 am".

Sorry - that got long - got carried away by my next work project to educate about hospice care in the hospital....

RainMom · Jul 30, 2016

Tapatalk. Is. Awesome.

...that is all...

LadyFree28, BSN, LPN, RN · Jul 30, 2016

I agree that there is some amount of burnout, frustration ,discouragement, and hopelessness generally speaking in healthcare and more so in nursing.
I learned this week that the above is a result of time constraints, excessive regulations, reimbursement changes, and short staffing. The reality between expectations of productivity and actual facts can be concerning. For example: "Slower and intuitive thinking is often more effective than mental agility" .
And :
Optimizing performance does NOT happen through increased productivity but through fruitfulness.
This comes straight from the textbook Quantum Leadership chapter 13 by Porter-O'Grady & Malloch (2015).
So what to do with the above thoughts and knowledge? Nursing care needs to be overhauled to ensure that nurses can actually do the value-based high quality patient-centered care everybody is asking for. It is a great idea but when a nurse has too many patients or /and a CNA that does have too many patients or MIA the nurse cannot achieve that. Instead, the nurse continues to run from task to task without time for reflection, thinking, or critical review of the bigger picture. And that employers see nurses and CNA mostly as productivity slaves that have no choice because economy is "bad" and nurses need jobs to make a living is unacceptable.
I learned that a low carb diet results in less endurance when working out and that headaches can be part of the adjustment.
Also, when you are on a low carb diet, the trip to the supermarket is mostly "Oh no - can't get that either - full of carbs". Changing a life style to low carb and counting carbs is not easy.
I learned that there is an ongoing confusion about hospice care in the hospital and the general inpatient benefit. Basically what seems to happen is that if a patient is in the hospital and elects to be CMO but is not imminently dying, the CM often ask for hospice to come out and evaluate if the patient meets criteria for the Medicare General In Patient benefit for hospice care. The CM often thinks of it as a cost reduction method - but that is not the way it is intended or should be used! GIP is for patients who are signed up for hospice care and who have so severe symptoms that they can only be managed through an inpatient stay. If that is the case, the options are usually hospice house or hospital or GIP care in a contracted nursing facility that has 24/7 direct RN care at the bedside. But - Medicare clearly states that this is short term and once symptoms are under control, the patient does not meet criteria for GIP and is only "routine hospice level of care".
What that means is this :
If a patient is in the hospital , becomes CMO and the CM says - well , just sign up for hospice and if you qualify for GIP you can die in the acute care hospital. Not really. If a patient is imminently dying or truly GIP they stay in the hospital but if they are not imminent (die within 24-48 hours) they need to be moved to a different setting. That can result in costs for room and board if the patient is not going home with home hospice.
Let's say a patient wants to go to the hospice house. The hospice evaluates the patient and says 'you qualify for GIP, we take you if you want to come here". The patient transfers. On day 1,2 and 3 the patient is very symptomatic and requires GIP level of care - Medicare pays. Now comes day 4 and the symptoms are under control, no need for change in dosing or anything - now the patient is routine level of care and Medicare won't pay for room and board. Lets say this happens at the 5 as well and on day 6 patient is GIP again. This will generate a bill because the days that the patient was not GIP appropriate but stayed in the hospice house, room and board will have to be paid for - it is usually several hundreds per day of routine hospice.
If a patient goes to a nursing home with hospice same deal. Now - if a patient also has Medicaid, medicaid will usually pick up room and board and medicare will pay for hospice. So basically, if you have low income and qualify for medicaid, you can go to a nursing home with hospice and it is paid for. If you have assets and not Medicaid the expectation is that the person uses some of their money for their care.
And - of course a patient of HCP has to agree to a hospice admission. Let's say the patient is in the hospital and is now CMO. The CM calls hospice to come out but is not clear about it with the patient or family. Hospice comes and finds that the patient is hospice appropriate and for that day GIP (because that is a day by day decision, you can not be GIP for the next week from the get go) and would like to admit the patient. But the patient or family do not want to sign up to hospice. The patient is still CMO and the CM now has to figure out what to do because the acute care hospital does not get reimbursed the usual rate for somebody who is CMO - is results in a loss of income so to speak.
What a lot of hospital staff forgets is this : The reason you should ask for a hospice to come in to admit a patient GIP is not to "save money" but to get expert level of care for a patient who is and the end of life and so symptomatic that expert advice would be in the best interest of the patient. Or you want to establish a relationship between hospice and patient/family. If a patient is in the hospital and accepts a GIP admission and signs on to hospice while in the acute care facility something happens:
Now the patient elected the Medicare Hospice benefit and is under the care of the hospice!!! That means that the hospice agency directs the care plan! The patient is still in the hospital, has nurses and physicians. The physicians order medications and such but the care plan come from hospice and hospice comes in daily (hospice RN) to assess the patient and manage their symptoms. They make daily recommendations for medications and the hospice medical director talks to the hospice nurse who puts the recommendations in writing.
Now the hospital has to take the recommendations and implement them! After all, the patient needs hospice expertise. They also have the spiritual coordinator, social worker and other staff involved. The hospital gets paid by the hospice agency now. I hope you guys see the problem with this arrangement: care coordination. Hospital physicians usually do not know that there are recommendations, nurses often do not know how GIP works because it is not that common.
http://www.nhpco.org/sites/default/files/public/regulatory/GIP_Tip_GIP_Sheet.pdf
If you made it until here you deserve a gold star! Are you more confused now? if yes - that is how it is for most nurses and even hospice staff has a hard time to understand this fully. There are many more small details that make it really chaotic.
For example : Longterm care facilities are very well versed to provide routine level of hospice care but most can not provide GIP level of care. Often because they do not have 24/7 RN coverage for that patient. And no - having a RN nursing director in the same building does not count, it has to be the assigned direct bedside nurse. And also no - it is acceptable to have an LPN cover the patient who is GIP level of care even if it is "only from 3 am to 7 am".
Sorry - that got long - got carried away by my next work project to educate about hospice care in the hospital....

There are so many regs in CMS, when used for their purpose, would make it so wonderful; including level of acuity assessments for nurses that I have used in the hospital and the hospice breakdown that you have explained; because I have worked closely with hospice during my years, I'm up to speed what you are talking about, and have corrected nurses, providers, and case management about this.

What we as clinicians should be doing is making sure our CEUs are up to speed about regulations, healthcare economics and EBP about how we can manage the regs to the fullest and challenge those that don't work.

Sent from my iPhone using Tapatalk

ixchel · Jul 30, 2016

I agree that there is some amount of burnout, frustration ,discouragement, and hopelessness generally speaking in healthcare and more so in nursing.
I learned this week that the above is a result of time constraints, excessive regulations, reimbursement changes, and short staffing. The reality between expectations of productivity and actual facts can be concerning. For example: "Slower and intuitive thinking is often more effective than mental agility" .
And :
Optimizing performance does NOT happen through increased productivity but through fruitfulness.
This comes straight from the textbook Quantum Leadership chapter 13 by Porter-O'Grady & Malloch (2015).
So what to do with the above thoughts and knowledge? Nursing care needs to be overhauled to ensure that nurses can actually do the value-based high quality patient-centered care everybody is asking for. It is a great idea but when a nurse has too many patients or /and a CNA that does have too many patients or MIA the nurse cannot achieve that. Instead, the nurse continues to run from task to task without time for reflection, thinking, or critical review of the bigger picture. And that employers see nurses and CNA mostly as productivity slaves that have no choice because economy is "bad" and nurses need jobs to make a living is unacceptable.
I learned that a low carb diet results in less endurance when working out and that headaches can be part of the adjustment.
Also, when you are on a low carb diet, the trip to the supermarket is mostly "Oh no - can't get that either - full of carbs". Changing a life style to low carb and counting carbs is not easy.
I learned that there is an ongoing confusion about hospice care in the hospital and the general inpatient benefit. Basically what seems to happen is that if a patient is in the hospital and elects to be CMO but is not imminently dying, the CM often ask for hospice to come out and evaluate if the patient meets criteria for the Medicare General In Patient benefit for hospice care. The CM often thinks of it as a cost reduction method - but that is not the way it is intended or should be used! GIP is for patients who are signed up for hospice care and who have so severe symptoms that they can only be managed through an inpatient stay. If that is the case, the options are usually hospice house or hospital or GIP care in a contracted nursing facility that has 24/7 direct RN care at the bedside. But - Medicare clearly states that this is short term and once symptoms are under control, the patient does not meet criteria for GIP and is only "routine hospice level of care".
What that means is this :
If a patient is in the hospital , becomes CMO and the CM says - well , just sign up for hospice and if you qualify for GIP you can die in the acute care hospital. Not really. If a patient is imminently dying or truly GIP they stay in the hospital but if they are not imminent (die within 24-48 hours) they need to be moved to a different setting. That can result in costs for room and board if the patient is not going home with home hospice.
Let's say a patient wants to go to the hospice house. The hospice evaluates the patient and says 'you qualify for GIP, we take you if you want to come here". The patient transfers. On day 1,2 and 3 the patient is very symptomatic and requires GIP level of care - Medicare pays. Now comes day 4 and the symptoms are under control, no need for change in dosing or anything - now the patient is routine level of care and Medicare won't pay for room and board. Lets say this happens at the 5 as well and on day 6 patient is GIP again. This will generate a bill because the days that the patient was not GIP appropriate but stayed in the hospice house, room and board will have to be paid for - it is usually several hundreds per day of routine hospice.
If a patient goes to a nursing home with hospice same deal. Now - if a patient also has Medicaid, medicaid will usually pick up room and board and medicare will pay for hospice. So basically, if you have low income and qualify for medicaid, you can go to a nursing home with hospice and it is paid for. If you have assets and not Medicaid the expectation is that the person uses some of their money for their care.
And - of course a patient of HCP has to agree to a hospice admission. Let's say the patient is in the hospital and is now CMO. The CM calls hospice to come out but is not clear about it with the patient or family. Hospice comes and finds that the patient is hospice appropriate and for that day GIP (because that is a day by day decision, you can not be GIP for the next week from the get go) and would like to admit the patient. But the patient or family do not want to sign up to hospice. The patient is still CMO and the CM now has to figure out what to do because the acute care hospital does not get reimbursed the usual rate for somebody who is CMO - is results in a loss of income so to speak.
What a lot of hospital staff forgets is this : The reason you should ask for a hospice to come in to admit a patient GIP is not to "save money" but to get expert level of care for a patient who is and the end of life and so symptomatic that expert advice would be in the best interest of the patient. Or you want to establish a relationship between hospice and patient/family. If a patient is in the hospital and accepts a GIP admission and signs on to hospice while in the acute care facility something happens:
Now the patient elected the Medicare Hospice benefit and is under the care of the hospice!!! That means that the hospice agency directs the care plan! The patient is still in the hospital, has nurses and physicians. The physicians order medications and such but the care plan come from hospice and hospice comes in daily (hospice RN) to assess the patient and manage their symptoms. They make daily recommendations for medications and the hospice medical director talks to the hospice nurse who puts the recommendations in writing.
Now the hospital has to take the recommendations and implement them! After all, the patient needs hospice expertise. They also have the spiritual coordinator, social worker and other staff involved. The hospital gets paid by the hospice agency now. I hope you guys see the problem with this arrangement: care coordination. Hospital physicians usually do not know that there are recommendations, nurses often do not know how GIP works because it is not that common.
http://www.nhpco.org/sites/default/files/public/regulatory/GIP_Tip_GIP_Sheet.pdf
If you made it until here you deserve a gold star! Are you more confused now? if yes - that is how it is for most nurses and even hospice staff has a hard time to understand this fully. There are many more small details that make it really chaotic.
For example : Longterm care facilities are very well versed to provide routine level of hospice care but most can not provide GIP level of care. Often because they do not have 24/7 RN coverage for that patient. And no - having a RN nursing director in the same building does not count, it has to be the assigned direct bedside nurse. And also no - it is acceptable to have an LPN cover the patient who is GIP level of care even if it is "only from 3 am to 7 am".
Sorry - that got long - got carried away by my next work project to educate about hospice care in the hospital....

The two words in my brain after reading this are "nurse liaison." In healthcare, education (especially to naysayers) is the way to bridge these gaps.

I've had one patient go GIP on my shift and everyone was all a-flutter to get it in the computer NOW, NOW, NOW. I know cutting costs is actually important, but damn. We're nurses, not vultures.

Sent from my TARDIS using Tapatalk

nutella, MSN, RN · Jul 30, 2016

The two words in my brain after reading this are "nurse liaison." In healthcare, education (especially to naysayers) is the way to bridge these gaps.
I've had one patient go GIP on my shift and everyone was all a-flutter to get it in the computer NOW, NOW, NOW. I know cutting costs is actually important, but damn. We're nurses, not vultures.
Sent from my TARDIS using Tapatalk

I actually worked in hospice and also as a hospice liaison and that does not solve that problem because the liaison nurses are not there 24/7.

meanmaryjean, DNP, RN · Jul 30, 2016

My dad died this morning.

He was 87 and had Parkinson's and dementia.

In 1976, when I got a last-minute offer of admission to the Springfield School of Practical Nursing- he gave me the $650 to attend. (That covered tuition, books, uniforms and supplies.) He got to see me receive my DNP in May via video feed.

Much of what I am- I owe to him.

OrganizedChaos, LVN · Jul 30, 2016

My dad died this morning.
He was 87 and had Parkinson's and dementia.
In 1976, when I got a last-minute offer of admission to the Springfield School of Practical Nursing- he gave me the $650 to attend. (That covered tuition, books, uniforms and supplies.) He got to see me receive my DNP in May via video feed.
Much of what I am- I owe to him.

*hugs* I'm so sorry for your loss. I have no words but I am so sorry.

Editorial Team / Admin · Jul 30, 2016

My dad died this morning.
He was 87 and had Parkinson's and dementia.
In 1976, when I got a last-minute offer of admission to the Springfield School of Practical Nursing- he gave me the $650 to attend. (That covered tuition, books, uniforms and supplies.) He got to see me receive my DNP in May via video feed.
Much of what I am- I owe to him.

I am so very sorry, meanmaryjean.

nutella, MSN, RN · Jul 30, 2016

My dad died this morning.
He was 87 and had Parkinson's and dementia.
In 1976, when I got a last-minute offer of admission to the Springfield School of Practical Nursing- he gave me the $650 to attend. (That covered tuition, books, uniforms and supplies.) He got to see me receive my DNP in May via video feed.
Much of what I am- I owe to him.

Meanmaryjean - I am so sorry for your loss.

I am glad he got to see you graduate - he must have been so proud!!

LadyFree28, BSN, LPN, RN · Jul 30, 2016

(((((MMJ)))))

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abbnurse · Jul 30, 2016

My dad died this morning.
He was 87 and had Parkinson's and dementia.
In 1976, when I got a last-minute offer of admission to the Springfield School of Practical Nursing- he gave me the $650 to attend. (That covered tuition, books, uniforms and supplies.) He got to see me receive my DNP in May via video feed.
Much of what I am- I owe to him.

I'm so sorry about the loss of your dad. How wonderful that he got to see you receive your DNP ! He must have been so very proud of you. (((((hug))))

Raven Sierra, BSN, RN · Jul 30, 2016

My dad died this morning.
He was 87 and had Parkinson's and dementia.
In 1976, when I got a last-minute offer of admission to the Springfield School of Practical Nursing- he gave me the $650 to attend. (That covered tuition, books, uniforms and supplies.) He got to see me receive my DNP in May via video feed.
Much of what I am- I owe to him.

Hugs to you. I'm so sorry for your loss.