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The Gap RN: Home Health Care's Failure.

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Rumble channel description: I've been a Home Health RN Case Manager for 12 years. I've switched jobs many time hoping to find an employer who is willing to pay Home Health clinicians to actually do the work mandated by CMS (the governing body of Medicare.) In one way Home Health works well: as a service that can save money and keep patients at home by providing periodic technical services. This is task based work and while it technically requires an RN, it is hard to justify the license protectionism used to require an RN for a job that only requires a short list of repetitive skills & minimal nursing assessment. Task based work is needed for about half of the patients followed by HH. For patients coming home with an IV (PICC/Midline really), that's fine, but what of the patient just returning home from the hospital after a heart attack with a new pile of pill bottles, a stack of illegible paper work, and no energy to adapt to their newly prescribed lifestyle? These people need Case Management. Home health regulation requires RNs to provide case management, which includes a wide range of tasks from clarifying MD communications, educating the patient/CG, modifying behavior, connecting resources & on & on. Case Management is 1. Time consuming. 2. Hard to measure and justify worker's need for higher pay. 3. Unpaid, easy to lie about and therefore often not provided. 4. vulnerable to a spectrum of time delays from waiting on hold with MD to educating patients who want to tell you stories about the grandkids. 5. LVNs can do tasks. Case Mgmt requires an RN with extensive medical knowledge, communication skill, etc. 6. Finally, if done correctly, Case Management can be the most valuable service HH clinicians provide, even in cases where we were referred for simple task work like wound care or IV mgmt; an LVN will change your bandage but an RN asks "why did you get the wound in the first place?" But, obviously, the old cliche holds true for labor and quality of care in HH: YOU GET WHAT YOU MEASURE. During an agency's every other year state survey, HH clinicians (only a few selected by management!) are tested on a few silly skills like "clean bag technique". Surveyors go on a few visit with clinicians and the sit down at a computer to assess our practice by reviewing our documentation. AND.... You get what you measure. HH Agencies have teams of QA auditors to review paperwork, maximize billable ICD-10 codes, and make sure the clinicians' paperwork LOOKS good for survey. You get what you measure. You can measure wounds, that an IV (PICC) dressing was changed weekly & foley cath monthly. You can easily read nursing documents to see the nurse CLAIMED to have taught CHF management and the pt/CG verbalized/demonstrated understanding; they WILL NOT look at time stamps and QA notes to discover this intervention only got documented after the note was returned for correction by QA. It would be costly for the state to follow a nurse for the management of a 60 day POC to see if they actually do what they document; why do intense, random in depth regulatory assessments that would produce a safe & effective Home Health Care industy, when you can check everyone on a predictabe schedule after giving them a cheat sheet? So. The tax payers get what CMS measures: a $129 Billion medicare funded HH industry that changes band-aids and produces terrific documentation. This system is failing so badly that CMS has started experimenting with austerity. They changed the payment structure to resemble No Child Left Behind. Agencies who perform poorly on CMS's chosen metrics get paid up to 3% less for the next year. These metrics are also used to assign a Star rating which referral sources can use to provide new business in the form of new patient referrals. But what are those CMS metrics? Do you want your mom going to a 5 star agency? Because You Get What You Measure and you'd be surprised what some of these measurements are. As a nurse I'm even more surprised how difficult it is to find any primary research referenced by CMS to justify these metrics or any of their regulations. I'm a nurse. You'd expect I could go on CMS.gov, a medical regulator, and find useful information. But there is little medical language at CMS.gov. The lexicon used is one of lawyers, business & accountants. On initial glance, most of the publications and public Q&A at CMS.gov involve figuring out who gets paid, licensing requirements, and what bureaucratic forms to fill out. Even the one good item I found, "State Operations Manual. Appendix D - Guide to Surveyors" contains pages of detail on computer network security (which should be handled by a third party!) and only the most abstract of descriptions akin to what you'd see in a job posting when mentioning Clinician's responsibilities and how HH is to care for their patients. You get what you measure; some metrics ensure quality pt care, while others gloss over the labor requirements implied by regulations to justify a pay structure that refuses to allow clinicians the time needed to do their job. Fraud is an open secret in HH. They won't say it out loud, but fraud is held up by management as the gold standard as demonstrated by their star nurse (the one billing 10 visits/day) to a poorly educated, over worked labor force who generally gets all their education about home health filtered through agency managers for whom profit is the only priority. There's A LOT of clinicians that are happy with this set up. They can get paid to do 10 visits/day, create fraudulent documentation and make $200K/year for making idle chit-chat with patients. I went into nursing because I thought it sounded like honest, fulfilling work for good pay. But the better I get at my job, the more time consuming it is, and since we are paid per visit, I find myself with a decade of experience and unable to support myself despite knowing the job better than most of my peers. We don't even get OT! We are (illegally in CA) classified as exempt employees because it is a skilled profession & we can supposedly use our judgement to reduce the demands on our time. But nurses use the Nursing Process: we are mandated to DO SOMETHING if we see a problem, and as your assessment skill increases, you see more problems. YouTube is full of HH nurses providing life hacks to streamline the HH work flow, but I have seen nothing that can turn the 60-80 hour FT caseload into a livable, ~40 hour work week. If we practice according to the law, we have little ability to control how long a job takes. The other YT videos are all titled "Why I quit HH in 6 months." In conclusion, there are 3 kinds of HH clinician: Ex, criminally negligent, and economically abused. The purpose of this channel is to explore in detail How and Why HH regulations are what they are as I go down a list of problems I've observed and seek documentation to justify the absurd. I hope to inspire other clinicians (and lawyers/accountants who can translate CMS.gov) to participate, ask questions I haven't thought of, and help fix an industry who's philosophy I love, but who's negligence and abuse I can no longer tolerate. - TheGapRN@proton.me