Allnurses Central

Do you favor healthcare rationing?

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I know some people may explode at this proposal, but does anyone out there favor forms of healthcare rationing? I’ve thought about two types:

1. If a person’s body is no longer able to function without minimal support, and having no chance for recovery, letting “nature take it’s course.” (Illustrated by the last vegetative state patient I remember having to putting 9 meds down their G-tube, along with continuous feeding, total incontinence, etc.)

2. “Covenant dependent” services, i.e. requiring patients to actively take steps to manage their issues in order to continue to receive healthcare resources (Inspired by watching my COPD pts leave the unit to get their smokes, addicts having PICC lines for treatment of drug abuse related infections sneaking out, scoring and using their lines to inject, etc.)

Is it really so unreasonable to say we don’t get a healthcare “blank check” from society?

Health Care Reform and Long-Term Care

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After a year of rancor and wrangling, partisan politics, strident public debate, rallies and protests, back-room deals, and media brawls, the Patient Protection and Affordable Care Act (PPACA) finally passed the House of Representatives in March 2010. It was amended into the final version by the Health Care and Education Reconciliation Act, which was signed into law by President Barack Obama on March 30, 2010. 

At first, few had any idea as to what sorts of provisions were included in the 2310 pages of this verbose historic legislation. It was quite the surprise to discover that the PPACA contains several provisions significantly affecting long-term care that will start taking effect over the next four years.

The demographic shift in increased numbers of elderly in our society will cause a shift in focus from acute care to long-term care health services. The present long-term care system, however, is not prepared for the burgeoning elderly population and is in dire need of reform. Weaknesses are many and include: reimbursement-driven and inequitably-distributed services; a fragmented, uncoordinated, and “user-unfriendly” system; a confusing blend of health and social services; multiple entry points; domination by the acute care system; poor public image; and, inadequate support for informal caregivers.

The following summary outlines key provisions of the PPACA for long-term care: 1) introduction of national long-term care insurance; 2) expansion of Medicaid options for community based services and supports; 3) mandating chronic care coordination; 4) more stringent criminal background check requirements for prospective long-term care employees; and, 5) nursing home reforms (the transparency provisions).

The Community Living Assistance Services and Supports (CLASS) Act establishes a new federally administered voluntary long-term care insurance program that will be financed by participating enrollees. This program is an entirely new public-private enterprise to finance and access long-term services and supports in the home or in a facility. Individuals will be automatically enrolled if their employers agree to participate. Premiums will be paid through payroll deductions unless the employee opts out. Many details in the new program have yet to be determined. The CLASS Act may end up crowding out the private long-term care market, which was not that significant in the first place.

The PPACA expands Medicaid and Medicare community-based long-term care pilot and demonstration programs to improve quality and reduce the cost of care, with the ultimate aim of keeping frail elders in their homes longer. These payment and delivery arrangements, if successful, may be expanded nationally. These include community-based prevention and wellness pilot programs, individualized wellness plans, the National Pilot Program on Payment Bundling, the Community First Choice Option, the Programs for All-Inclusive Care of the Elderly (PACE), the Money Follows the Person demonstration, and the Independence at Home demonstration program. The PPACA also introduces a three-pronged structural reform: single point of entry; case management; and standardized eligibility/ need assessments. 

The chronic care coordination provisions are a diverse set of new initiatives offered through the PPACA with the goal of better coordinating the care of individuals with multiple chronic conditions. Addressing care coordination is a critical issue in health care payment reform, since many people with multiple chronic illnesses need expensive long-term care services. Presently, care for chronic conditions is poorly coordinated, and the costs of care are increasingly shifted to the client. Care coordination initiatives include: more closely aligning Medicare and Medicaid for dual enrollees; enhancing linkages between health care needs and long term care services; improving primary care provisions for persons with multiple chronic conditions; and, facilitating seamless transitions in care settings across the entire health care continuum. In accordance with these initiatives, the PPACA calls for the establishment of a federal coordinated health care office, Medicare Special Needs Plans, and medical health homes.

The PPACA requires the establishment of a nationwide program for background checks of direct care employees in a wide variety of community and institutional long-term care entities. The new requirements cover employees of nursing facilities, assisted living facilities, intermediate care facilities, and providers of home health, hospice, and adult day care services. 

The nursing home transparency provisions are the most sweeping reforms in nursing home quality since the Omnibus Budget Reconciliation Act (OBRA) of 1987. The PPACA provisions require disclosure of ownership, governance, and indirect controlling interests. When fully implemented, the law will provide consumers a substantial amount of new information about individual facilities. The Medicare Nursing Home Compare website will contain staffing data; links with information regarding state surveys, inspection reports, and certification programs; information on accurately interpreting these reports; and, facility responses to these reports. Additionally, the Nursing Home Compare site will include a consumer rights information page.

These reforms are a good start in addressing some of the weaknesses in the present-day system of long-term care. However, they are not the comprehensive overhaul that the long-term care system so desperately needs. The wording for many of these provisions is distant and vague. It is also troubling that many of these mandates, especially the expansion of Medicaid, are unfunded, and risk further bankrupting the states. It will be interesting to see how these reforms unfold over the next few years to decades as the massive baby boomer cohort enter their senior years.

References

Healthcare Reform: Implications for Long-Term Care Providers

Justice, D. (2010). Long term services and supports and chronic care coordination: Policy advances enacted by the Patient Protection and Affordable Care Act. Portland, ME: National Academy for State Health Policy. Retrieved from http://www.nashp.org/sites/default/files/LongTermServ%20Final.pdf

Pilot Programs and Demonstration Projects – The Patient Protection and Affordable Care Act (PPACA) and Health Care and Education Reconciliation Act of 2010

Pratt, J. (2009). Long term care: Managing across the continuum (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers, Inc. 

Program of All-Inclusive Care for the Elderly (PACE) 

Public Health, Workforce, Quality, and Related Provisions in the Patient Protection and Affordable Care Act (PPACA)

Text of Patient Protection and Affordable Care Act

Medicare, Medicaid, and the Elderly Healthcare Consumer

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Exploring the complex subject of Medicare and Medicaid healthcare services for the older population. A brief history of both entitlement programs, the eligibility criteria, the similarities and differences, the strengths and weaknesses, services provided, regulatory agencies, and the financing mechanisms for each are compared and contrasted. Implications for the future are also explored.

The Medicare program was created in 1965 as Title XVIII of the Social Security Act. Its primary purpose was to provide health care coverage for the elderly, who were defined at that time as anyone 65 years of age or older. In 1972, provisions were added to include people who were permanently disabled and those with end-stage renal disease. 

Medicare is the chief federal government program that pays for health care for 40 million Americans over age 65 and another 7 million disabled people of all ages. Medicare has serious limitations: It does not pay for the first day of hospitalization; it also does not cover hearing aids, eyeglasses, or dental care. It lacks an emphasis on preventive care. Additionally, it excludes coverage for long-term care services and supports, except for limited periods after hospital discharge. 

Medicare is a federal health insurance program. It is the nation’s largest federal health insurance program, covering nearly 47 million Americans (i.e., one in seven Americans). It is basically the same everywhere in the U.S., and is run by the Centers for Medicare and Medicaid Services (CMS), an agency of the federal government. Medicare funding comes primarily from three sources: payroll tax revenues, general revenues, and premiums paid by recipients. 

For senior citizens, eligibility for Medicare is not tied to individual needs (income) or to health status. Rather, it is a federal entitlement program; beneficiaries are entitled to it because they or their spouse paid for it through employment or self-employment taxes. The Medicare program is the first level safety-net for America’s elderly and disabled.

Medicare was created in an attempt to address the fact that many older citizens have medical expenses significantly higher than the rest of the population, while it is much more difficult for most seniors to continue to earn enough money to cover those costs.

At the same time that the Medicare program was developed to provide health care for the elderly, Congress also created Medicaid as a program to provide health care for the poor. Enacted as Title XIX of the Social Security Act, Medicaid is different from Medicare in several very specific ways. 

Medicaid is a joint federal and state health care assistance program for low-income, financially needy people, set up by the federal government and administered differently in each state. It helps pay medical costs for people with limited income and resources. Medicaid serves the “medically indigent,” those who have no other coverage, and cannot afford to pay for their own care. It is run by state and local governments within federal guidelines set by CMS. 

Like Medicare, Medicaid is also a federal entitlement. Eligible persons cannot legally be denied medical assistance, even if the state is facing a massive budget deficit. Waiting lists and enrollment caps are prohibited. 

Medicaid programs vary from state to state. Federal guidelines require states to provide 16 basic healthcare services for elderly Medicaid beneficiaries. These services include inpatient and outpatient services, primary care provider services, skilled and intermediate nursing facility services, laboratory and medical imaging services, and home health care. Other services, such as physical therapy, rehabilitation, prescription drugs, hospice, and transportation, are optional. 

An estimated 60 million Americans are covered by Medicaid, with the enrollment numbers swelling due to the economic recession. To further stress state financing mechanisms, the new PPACA healthcare reform legislation could add 16 to 23 million people to the Medicaid rolls due to Medicaid expansion. In addition to the considerable drain on state budgets, there are federal budget considerations as well. Currently, Medicare, Medicaid and Social Security consume more than 40 percent of the federal budget. This startling figure will be overshadowed in the next few decades as the massive baby boomer cohort enter their senior years.

Although an individual may qualify for and receive coverage from both Medicare and Medicaid, there are separate eligibility requirements for each program. Being eligible for one program does not necessarily mean someone is eligible for the other. Also, Medicaid pays for some services for which Medicare does not. If a person is eligible for Medicaid, Medicaid may pay Medicare deductibles and the Medicare premium.

The people who qualify for both Medicare and Medicaid programs are called “dual eligibles.” Approximately 8.8 million Medicaid consumers are simultaneously enrolled in Medicare. These individuals are among the nation’s most vulnerable populations – seniors and non-elderly people with disabilities. Most are low-socioeconomic status, in poor health, and have complex comorbid healthcare needs. Given these social and health circumstances, duals are a costly population for whom to provide coverage.

Medicare and Medicaid work together to pay health care costs for low-income persons. Medicare pays first. Then, Medicare recipients with low incomes may also be eligible to receive aid from Medicaid to cover many of the costs not covered by Medicare. For those who are fully covered by Medicaid, the Medicare health care coverage is supplemented by services provided under their respective state’s Medicaid program. Some of these services include:

  • Nursing facility care beyond the 100-day limit provided by Medicare.
  • Prescription drugs.
  • Eyeglasses.
  • Hearing aids.

References

Center for Medicare Advocacy

Medicare & You 2010

Medicaid and North Carolina’s Aging Population

The Medicaid Program at a Glance

Royal Flying Doctor Service

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I have a story to tell you about the Flying Doctor in Western Australia.

This year marks the 75th anniversary of the Royal Flying Doctor Service in West Australia, and the Western Australian State Library is holding an exhibition to mark this.

Some 60 years ago, I witnessed my first Flying Doctor recovery, some 300 miles East of a little town called Wiluna in West Australia.

My dad was the manager of Carnegie Station [cattle property] East of Wiluna, and a stockman had come off a horse and broken his leg pretty badly. The Flying Doctor was called via the pedal radio [ie the radio was actually powered by pedalling the generator to provide power] and a couple of hours later, the doctor appeared in the form of a tiny little Auster two seater plane piloted by a RFDS doctor whose name was Dr Harold Dicks. Now, at the time, I was 4 years old and full of curiosity, so this thing appearing out of the sky was pretty amazing to me. My sister got frightened and disappeared under a bed!!!

Eventually, the plane landed in a cloud of dust-I though it had hit the ground and been destroyed!!!!

Out came the pilot who took the right hand door off the plane and proceeded to strap the patient to a rudimentary stretcher with the aid of the station workers. They then tilted the stretcher on its side and slid it into the plane and tied it to the floor next to the pilot’s seat. While this was going on, my Mother had a fire going on the side of the airstrip with a billy of tea on, so the pilot had a quick drink of tea and then took off for his long flight back to the hospital with the patient.

This was probably an easy job for the pilot/doctor. Sometimes it may well have involved a PT with appendicitis or similar.

After seeing that plane, I made myself a promise, that I would learn to fly one of those things and become a doctor. Well, I did learn to fly, but never became a doctor but I am an Ambulance Officer and a rural nurse.

The upshot of all this is that last week, I won a competition run by the Flying Doctor and the Western Australian State Library to tell a story about early experiences with the Flying Doctor.

I told this story because I think it so important to preserve history.

My prise included a return flight to Perth on Skywest Airlines, two nights at the Hilton in Perth, and tours of the Library and the Flying Doctor facilities at Jandakot Airport, the second busiest in the southern hemisphere.

Also, I won a flight in a Boeing 737 simulator, which is a complete 737 cockpit in a building and enables you to “fly” pretty much anywhere in the world. Suffice to say we didn’t do any “gardening” with it and are still very much alive!!!

In the bush in Australia, the Flying Doctor is our lifeline. We would be hard pressed to survive without them. They provide aeromedical evacuation at no cost plus on call consultations and a full range of high level drugs.

The Flying Doctor has been the longest love of my life, spanning 60 years.

What my patient taught me about life

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We have so much to be thankful for, and often we forget that. My patient opened my eyes to what I’ve been missing.

Life is short and precious. Often, we take it for granted. The funny thing is that we don’t even realize that we do it. Its human nature to complain, to always want something more, to seek out the better… its second nature to us. It often takes a person or event to catch our eye to make us realize all the joy we’ve been missing. The moment I realized this was when I started my current job.

Last November I was let go from my non-nursing job. Eager for work, I found an agency online and applied. They called me immediately about a case they had available. It sounded like a great case, but I never went in for my interview. I ended up leaving the country for a week, and then I got wrapped up in the holiday season. Once things settled after the new year, I again applied with this agency. This time I went in for an interview. The case they described was the exact one they wanted to put me on months before. Now, I’m believe everything happens for a reason. Seeing as how I was offered the same position twice, I accepted immediately. I knew there had to be a reason I was on this case.

I was assigned to Asher*. A sweet little boy with a seizure disorder, spina bifida and Arnold Chiari malformation. I was very nervous when I went to meet him for the first time. I’ve cared for kids before, but not kids with diagnosis’ like this. In fact, the agency even told me that this was one of their more difficult cases. I was intimidated to say the least. G-tubes, trachs, continuous O2, seizure precautions, and disease processes all had me scared out of my mind. The only thing that didn’t keep me from bolting out the door was the fact that I was offered this case twice. I gave myself a good pep talk, and headed to Asher’s house. When I walked into the room, I saw Asher, sitting in his bed, big smile on his face. He seemed like a happy child, which help ease my worries with this case. After my first shift, I started relaxing a bit. Maybe it wouldn’t be so bad after all.

My first few months were rough. Adapting to the equipment, environment and schedule proved more difficult that I imagined. But the one thing that kept me coming back was Asher. Every time I’d start my shift, his whole face would light up. He’d tell me about his day, laugh at my silly jokes and always wanted me to be near to him. The only time he would cry was when he didn’t get his way. I began to love work. When my friends and family would ask me about Asher, I’d tell them the basics (after all, I am bound by HIPPA). Everyone always had the same reaction, “Oh, that poor boy. Life must me miserable for him”. At first, when I started getting these reactions, I was confused. I had told them with a smile on my face and joy in my voice, how did they get ‘miserable’ out of that? I started asking them why they thought these things. The typical answers were about poor quality of life, not being able to do things other kids his age could do, ect. It disappointed me to hear such things. I had a completely different outlook on Asher’s situation. Thats when I realized how much Asher had taught me about life.

Lesson #1: Physical touch is important. Being near another human being and feeling their presence is a wonderful thing. Asher always was holding my hand and giving me hugs. He was showing me love, and I was showing him the same. Sometimes if Asher was having a bad night, all I had to do to fix it was rub his head, or play with his hair. After I realized the importance of physical contact, I began evaluating my own life. I realized I always felt better when I had physical contact of some kind with a friend or family member.

Lesson #2: Happiness is what you make it. Joy and contentment are a state of mind. Asher is a happy boy. He’s not upset or bitter about all the things he can’t do. He loves his life, and he loves sharing it with others. Every month he gets to go into his 4th grade classroom. This last month he answered all the questions the kids had for him all by himself. He loved every second of it. When I came in to work that night, he spent a significant amount of time telling me all about it with a huge smile on his face. His amazing outlook on life makes his quality of life better than most people I know.

Lesson #3: What I did by deciding to stay on my case wasn’t just good for Asher, it was good for the family as well. Taking care of Asher is a full time job, and they were without weekend night help for quite some time. By accepting and staying on this assignment, I was a blessing to the parents. They never stop showing me their appreciation. Not only am I making a difference in one life, but others as well. As nurses, we never know who can be affected by our actions, positive or negative. This case has been a great reminder to me that we affect all we come in contact with.

This case has provided me with a new outlook on life. I am thankful for all I have, and for every person who invests into me. Asher showed me just how great life can be. Like the saying goes… if life gives you lemons, make lemonade.

*Name changed for privacy purposes.

My cookies are getting pretty frosted now – Discussion about “House”

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We’ve discussed the representation of nurses on television programs before. Generally, with very few exceptions, we are portrayed as invisible, obedient, unthinking servants. But has anyone noticed on House lately, a show widely criticized for not having any nurses working in its hospital at all, has one nurse character that has bopped her way into increased screen time?

I’ve been watching her for several weeks now and I still haven’t caught her name. She appears all over the hospital, but can most often be seen outside the office of the Dean of Medicine playing secretary… or usherette, I’m still not sure which. She pops in to tell the Dean that So-and-So is here to see her now, or that another So-and-So is waiting somewhere for their meeting. She turns up wherever the Dean of Medicine is, injecting information and advice about whatever the Dean of Medicine is up to. She reminds the Dean of meetings, of previous commitments, of whatever. The Dean of Medicine generically asked her to “check the per diem schedule for conflicts” and the nurse generically got right on it. She never talks about nursing. She never talks about medicine. She wears plain blue scrubs and has a stethoscope around her neck and a chart in her hand. Did I tell you I haven’t caught her name yet? She sure gets a lot of screen time following the Dean of Medicine around though, wow! Anyone who didn’t know any better would think she worked for the Dean of Medicine. Unfortunately, most people don’t know any better.

A Frustrating Morning…

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I am so angry and frustrated right now that I feel as though I may blow a fuse at the moment.

We just had a very frustrating fifteen minutes on the phone. AARRUUUGGGHHH! Shortly after we got up this morning, Frank, our eleven year old neutered cat peed in an antique sterling silver dish that had been my great grandmother’s. It was sitting on the floor, where it had fallen down. We have 12 oversized litter pans which are cleaned daily morning and night. Frank has never ever sprayed or gone
ooutside of the box in his whole life — not once… not ever.

We called the clinic we have used since 1981. That’s thirty years or three entire decades!
Our instructions are to call ahead to tell them we’re on the way, then bring the animal out
when something suddenly crops up that even might be serious or if the animal seems uncomfortable
or in pain. Our vet and his wife are friends of ours and we have their home number and cells, but
this wasn’t that type of emergency.

“Good morning! ___ ___ Clinic” (unfamiliar voice)
“Hi! This is ___ Jones (fake) and I’m calling about Franklin the cat, who is 11. He peed outside
the litterbox this morning and he’s never done that before. He seems uncomforta—”

“WHAT did you say your NAME was again?”
“__ JONES. ”
“HUH?”
“___ JONES. J-O-N-E-S”
“Bones?”
“JONES! JONES! J-O-N-E-S! Like the car dealership that advertises on channel 35 all the time.”

“Speak up, lady! Quit mumbling and then MAYBE I could hear you!”
“My first name is ___!
“HUH?”

“I’m leaving now to bring Frankie out.”
“HUH?….You can’t do that! I didn’t give you permission!”

Phone rings…

“Hi! This is Jon. (the vet) What’s going on with Frankie?”
I give him a quick run down and tell him Frank and ___ are enroute.
“Good decision”

Phone rings again…

“This is ___ at the __ __ Clinic! I just wanted you to know that you and your ^&*#@$% husband
just got me yelled at and #$%^&ed out and I just wanted you %$#@ers to know that I can $%^& up
your animals’ care whenever I want!”

I just hung up.

Now that I don’t have smoke coming out of both ears and have calmed down a little bit, my question is,
do we just forget it completely, or do I assume the vet would want to know about this flake? I know they have some serious issues going on with one of their children and I suspect that’s how this wingnut
got hired to begin with. But if she was that unprofessional and rude with me, she’ll do it with others too.
My concern is that I don’t want it to negatively affect his practice.

I forgot to mention the condescending five minute lecture on the need to keep litter pans clean and the admonishment that we are no one special and deserve no special tx. Didn’t think we did.

Best Pet For Busy Nurse

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I work three twelve hour shifts in the OR and am on call 5 days a month. I want a pet and cant decide what I should get. Suggestions?

Answers :

xtxrn : I paper trained my puppy (when she was one, 10 years ago- LOL), and she is still paper trained. She tolerated 12 hour shifts quite well, and was fine by herself. She had plenty of toys, and a lot of attention when I was home. Now that I’ve been on disability, I see how much she sleeps (even when she was 3-7 years old), and it wasn’t that different than if I’d have still been gone. They adapt, and love you no matter what.

No crate, no doggy daycare (I don’t board her- if I’m in the hospital, my Dad comes over daily to feed/water/change the pee pads).
I had a LTC office job when she was really little, so she came with me. When she was a few months old, I left her in the kitchen w/a baby gate (bigger than a crate). When she got past the teething phase, she’s had the run of the place ever since. Her biggest “crime” was taking the socks off of all of the feet of my doll collection dolls  They were piled up by the back door in a pile.

My 2nd schnauzer was a little booger as a puppy, and chewed on books (Tabasco on the edges fixed that- she was never forced to eat Tabasco, but if she got into eating the books, she learned it wasn’t a good idea). After that, she was good, but wouldn’t use the papers after I moved to another apartment. So, getting home on time was important. She could make it through a 12 hour shift ok, and did well with most 16 hour shifts. But I much prefer that the current dog will use the papers on command, and as she wants.

I got the people chux, too= those puppy pads hold about 4 drops.

 

Girlygirl69 :  I have a dog. I work the same hours as you as well. I really only do daycare when I need a break from her. She loves to play with other dogs for a few hours and I get uninterrupted peace. She is trained to go on the pad, never chews anything or destroys my apt., and I just leave a bowl of water and a little food when I go to work. I walk her when I get back from work, most days. Get a havanese, they are a very friendly breed and are low to no shedding dogs.

 

Rnwriter : We’ve had four rescued pugs over the years and loved them to pieces. They do need to be brushed/combed to keep shedding to a minimum, but other than that, ours were all easy peasy. They barked (a deep mid-sized dog woof rather than a small dog yip that would have driven me bonkers) only when they someone came to the door or for some other good reason.

After the first year, all four of ours settled down and turned into couch pillows. They loved to play, but also loved to sleep. These dogs are small but sturdy. The pug motto is, “Multum in parvo,”–a big dog in a little body.

They aren’t snappish or high strung, and they’re funny as all get out in appearance. They look kind of like teddy bears with floppy ears.

Ours used to tolerate long periods of being left alone. We did have the first two together, and that kept them content.

Hope this helps expand your search.

 

ICU_RN2 : I have a two year old Boxer. She’s great fun, never was destructive as a puppy – but that could be because my other half was home with her often. She went to work with him while she was a puppy, so she was never crated for long periods at home when she was little. We do crate her now when we’re gone, and very rarely does she go all day in the crate. Her energy level reflects whatever we’re up to…if we’re laying around the house all day, so is she. If we’re outside, she’s running around like a crazy dog for hours. She certainly has an endless supply of energy when she chooses to use it!!

I’d love to do doggy day care with her, but just an fyi – all the doggy day cares in my area open at 7 or 8am, and pick up time is before 6pm…I can’t seem to find one that has hours that work for my 7-7 shifts!

Good luck!!