Thursday, April 11, 2019

Fun Time Patient-Centered Graphic Nursology

Pay attention

Rachel Lindsay has Four Awesome Strengths(TM):
  1. Smart
  2. Funny
  3. Talented
  4. Brave
She's drawn them together and laid them out for us in her amazing story, Rx.  

Key point: It's. Her. Story. 

Her commitment to telling it goes back eight (8) years. It's that important.

It's a story about serious and repeated failures in response to simple, basic, and obvious human needs: to be seen, heard, and validated; to be given clear and useful information; to have advocates with standards for practice and ethics.

We're the failures in the story - systems and agencies and teams and clinicians.

Get the book and see how it influences your practice. 

Learn more about Rachel in this most excellent Interview on the T with Emoji Nightmare and Nikki Champagne, which also includes the bonus Time-lapse filmed by Meghan O'Rourke - August 2015. Music "Maybe it's Love," by R, 2007.

Tuesday, April 9, 2019

Manifesto Tuesday - 3 questions

it's not rocket science

Please also read my earlier post on the 4 admonitions in Death Nurse Manifesto, since these 3 questions directly relate to the admonitions that hospice agencies be transparent and not abuse their staff.

1. Do they have enough staff?

Every patient's and family's first need is for care that's safe.  One of the best indicators of an agency that can provide safe care is safe staffing - having enough staff on hand and available to provide good care.

What's the agency's average daily census (ADC)? 

It should be a simple number to obtain, and will generally range from less than 100 up to several hundred or more.

If the agency operates in multiple offices, get the ADC for the office that will be responsible for your care. 

You should also specify that you want the number for the same setting as yours (residing at home, in a long term or memory care facility, etc.)

How many full time hospice RN case managers (RNCM) does the agency currently have on staff to care for that population?

The RNCM is the most critical role in hospice, responsible for coordinating and supervising the hospice interdisciplinary group (IDG) that also includes health aides, social workers, chaplains, physicians, nurse practitioners, and others both inside and outside of the agency - like your longtime family physician, or your oncologist.

It's a full-time Monday-Friday gig, and there's never a dull moment.

Also ask if the RNCMs have other responsibilities, like covering evening or weekend on-call, and admitting patients and families. Additional duties undermine the purpose of the RNCM role.

Also, too: ask what the average case load is for RNCMs at the agency. It's sort of a trick question, but jot down the number if they answer: ______

Average Daily Census (ADC): _______
Full Time RN Case Managers: _______

ADC / RNCM = ______ (calculated average case load)

Compare with their answer, if given: ______

The given and calculated average RNCM case load can help us start to learn if they have enough staff. 

Beware of agencies that routinely overburden staff with high caseloads and/or require them to cover evenings, weekends,new admissions, etc. That's abuse. 

You need to also know the numbers and case loads for social workers, chaplains, and home health aides.

But if an agency can't find or retain enough staff, it will most often show up first among the RNCMs. An abusive agency culture means abuse for everyone.

Please also see Boo Boo's 2017 post Can one number tell us if this hospice is any good? (includes handy chart!)

2. Are the staff any good?

If you're satisfied that the agency seems to have an adequate quantity of staff, you next want to understand its quality.

Of course an agency is going to say their staff is universally qualified, and may even mention certifications and awards, or point to a press release.

Humans are biased about their own skills, and tend to overestimate what they know. They can also become defensive when confronted by a demand to, "Prove it!" 

You're not asking an individual about the quality of their work - you'll see it when you meet them. 

But you can get a sense of whether or not the agency is a place where people who do good work want to be by asking, "What's your annual turnover?"

It's important to know the turnover in general, but it's even more important as it applies to clinical staff and location.

For example, a 350-person agency that brags about 20% annual turnover is still talking about 1/5 of its staff - 70 people.

They're not telling the full story, either. The agency operates two locations - one site houses 300 people, including administration and back office staff, while the other houses 50, all of whom are clinical.

If 35 of the 70 people who left in one year worked out of the small office, and were clinicians, their effective turnover rate is 70% (35 out of 50). I'd want to know why, though simply knowing turnover was so high might be enough.

You may get a blank stare in response to your question about staff turnover. Or a hostile one. That's because the answer can be the clearest indication of an agency's negative practice environment, and the brightest red flag waving everyone away - clinicians, caregivers, and the community.

Don't give up, but if they won't answer, that's your answer. You can also search employee reviews at websites like Glassdoor and Indeed. There may not be large numbers of them compared to that pizza joint down the street, but things like the details of negative reviews, and their timing, can provide some insight.

If they won't talk about clinical staff turnover, I'd look for another agency. You could also ask about their use of temporary and contract clinical staff, often called 'travelers.' Bottom line: not a good idea in hospice.


3. Who are the staff?

I've visited lots of hospice agency websites over the years. Most of them fall into one of two categories, and often both:

- Awful
- Unhelpful

Lately it seems corporate hospice sites are moving to a model with little information beyond stock photos of sunflowers, bland brochure weaselspeak, and an 800-number direct to sales.

Those that still include any mention of actual people usually do it two ways:

- Shiny happy people smiling 
- Our leaders

Both are stupid, wrong, awful, and unhelpful.

Every hospice agency needs to list their staff roster on their web site - names, credentials, and roles. Bonus points for photos and extra bonus points for bios and staff-generated content. 

The only reason for an agency to not list staff is the same reason for not talking about safe staffing and staff quality - because the answer is unfavorable to the agency. 

You'll meet staff when they visit. But it would be best to have some idea of who they are, and who they work for, before they walk through your door. 

Please also see this post from 2018 about things that can go wrong - Sadly, not rare - #hospicefail

Thanks for reading, See you next time.

With love and respect for the memory of Melissa Reina
For her children, family, friends, and community

Wednesday, April 3, 2019

Orange Crate Update Number 2

It's money that matters

Quick update

The sole purpose of the Death Nurse Orange Crate of Publicly-traded Corporate Hospice is to educate clinicians, caregivers, and the community about companies looking to make a profit from providing services to patients and families facing serious illness and end of life.

1. People are dying.
2. ??????
3. Profit!!

Our first lesson is that the stock prices for all of the companies are lower at the end of the Orange Crate’s first month. 

Other news

Amedisys continues its strategy for inorganic growth with its purchase of RoseRock Healthcare. “RoseRock provides specialized hospice care to approximately 200 patients daily in northeastern Oklahoma. Amedisys currently operates six home health care centers in Oklahoma, including an agency in Tulsa.” 

The company posted an announcement in Facebook with the following message from CEO Paul Kusserow, “You’ve joined a nationwide team committed to the same principles of honoring life through excellent patient care that have made your company so successful - welcome to the family!"

I asked how getting bigger makes things better for patients and families, and the company responded: “Hi Jerry - By strengthening our family, we're able to serve more patients with purpose and ultimately improve how end-of-life care is delivered in the country. In joining forces with other hospice companies, we can introduce more scale, structure, regional support, technology and professional development to allow for better patient care.”

The language sounds like something from a brochure. The reasoning is unclear to me, but the thinking seems to be that buying other hospices is a way to get stronger and leads to taking care of more people (makes sense); “with purpose” means something that isn’t explained but is supposed to impress us; and will eventually make everything better for everybody in the country somehow sometime ("ultimately improve").

They also exude the singular confidence that by getting even bigger ("more scale"); imposing hierarchies, processes, and rules ("building structure"); adding bosses ("regional support"); getting laptops and/or smartphones and/or IT nerds and/or playing with data ("technology"); and making everyone watch webcasts ("professional development"); and by somehow doing all of this by “joining forces” (how?) with “other hospice companies” (who?).

We’ll see,

I replied, “Thanks for your response. I'm a shareholder, nurse, and severe skeptic of corporate and for-profit hospice. What you're doing bears close watching. In my experience, hospice doesn't scale. Also too: you said nothing about transparency, so I hope you're prepared and willing to honestly answer questions like, What's the average caseload for a full time RN case manager working with patients and families who live in their own homes? What's your turnover for clinical staff? Patients and families are starting to know more and demand better. I look forward to talking with you more.”

Encompass surprised watchers when it announced its plans to acquire privately-held Alacare Home Health & Hospice for $217.5M. That’s more than twice the amount the company previously told investors it planned to spend on its strategy of inorganic growth (i.e., to get bigger by buying other hospices).

Founded in 1970 by the Beard family, Birmingham-based Alacare operates 23 home health locations and 23 hospice locations in Alabama, generating revenues of approximately $117 million last year.”

“John Beard, Alacare’s president and son of Alacare’s founder, Charles D. Beard Jr., said the company was “fortunate to be able to choose" Encompass Health from a number of interested partners.”

“Susan Brouillette, Beard’s sister and Alacare’s CEO, said the company and Encompass Health have had a close working relationship for many years on policy and other issues affecting the industry.”

Maybe that’s what the PR folks at Amedisys meant by, “joining forces with other hospice companies.”

Also, too: Keep reading Generic Hospice Blog.

Thanks for reading. See you next time.

Thursday, March 28, 2019

Orange Crate Update Number 1

Earlier this month I announced the Death Nurse Orange Crate of Publicly-Traded Hospice Companies*. Timing is everything, because now is when these guys tell the world how much money they've made and/or try to explain why they didn't make enough.

I'm sifting through their assorted filings and reports, dense with legal disclaimers, marketing braggadocio, and accounting. I'm not going to tell you that I understand it all, because I don't. I'm not a lawyer, accountant, of Master of the Universe.

However, my bullshit detectors are finely tuned, and there's plenty of that kind of stuff in these reports, and in the associated materials that make up your typical investor road show.

My detectors quickly sniffed out two examples from Humana's (NYSE:HUM) latest, courtesy of my new friends at Seeking Alpha. They're not the only ones, but ya gotta start somewhere. 

Before we do, a quick review of the fundamental premise behind every company in the Orange Crate*:

1. People are dying.
2. ?????
3. Profit!!

Number one is fact. Number three is the goal. Number two? A combination of magical thinking and messy details. Do you see what I'm saying? Good, let's begin.


HUM's base business is selling health insurance, an industry where making money depends entirely on nickle-and-diming vulnerable patients, denying their claims, and squeezing their providers. 

They're doubling down on the whole Medicare Advantage thing because it's their direct pipeline to seniors, and we all know about seniors and health care dollars.

It's like when someone asked Willie Sutton why he robbed banks - you go where the money is. For our friends at HUM, that means the United States Department of Health and Human Services. The Centers for Medicare & Medicaid Services is its drive-up teller window.

So, right now they can pick the pockets of about 4 million people over age 65. Of course they want more, but it's enough to get started on exploiting the opportunity (People are dying).

Since we've already identified the final objective (Profit!!), the only thing that remains is replacing the question marks with... a circle and two pieces of the world's easiest puzzle. 

Wasn't that easy? Who says healthcare is hard? Next slide, please.


I previously posted about HUM's entry into corporate hospice through their minority (40%) partnership with two leveraged buyout firms (they'd rather we say "private equity") in the $5.4 billion blender called, "Kindred at Home." (smoothie still in progress) It's key to their "success" - $$ from the dying.

You'd think that HUM, which can arguably claim to be in the healthcare business, would insist on running the show. Surprise! 

Thanks for reading. See you next time.

Also too: Get thee to Generic Hospice Blog.

*For education only. This is not financial advice.

Tuesday, March 19, 2019

World Premiere - Death Nurse Cartoons!


A student film

I chose the name 'Death Nurse' without fully thinking through what it meant, but this is how it's evolving - as a character in a cartoon world that touches on contemporary life, serious illness, death and everything associated as frequently and in as many different ways as six seasons of the Sopranos (plus every episode of Deadwood, Six Feet Under, The Wire...). 

Aim high. Keep swinging.