Hiring a Home Health Care Employee

Providing the primary care for an elder loved one can be difficult. When you cannot deliver all the elder care yourself and support from friends, family, and community organizations is not enough, it may be useful to hire a home health care worker. He or she can offer care from a few hours a week to 24 hours a day, and can provide many other helpful services. Types of in-home health care services include:

General Health Management like administration of medication or other medical treatments
Personal care such as bathing, oral hygiene, dressing, and shaving
Nutrition help like preparing meals, assisting eating, and grocery shopping
Homemaking services including laundry, dishwashing, and light housework
Companionship for example reading to the senior or taking them on walks
Recruiting and Interviewing Applicants
There are many avenues for hiring a home health care employee. Generally, home health care workers can be hired directly or through an agency. Home health care agencies often have a staff that includes social workers and nurses that will manage your care. However hiring an independent home health care worker is generally more cost effective, it will also give you more control over the type of care you receive.

Senior home care workers should be carefully screened for proper training, qualifications, and temperament. Fully discuss the needs of the elder care recipient during an interview with a prospective home health care employee. There should be a written copy the job description and the type of experience you are looking for.

References

Have applicants fill out an employment form that includes the following information:

Full name
Address
Phone number
Date of birth
Social Security number
Educational background
Work history
Before hiring, you should ask to see the senior home care worker’s licenses and certificates, if applicable, and personal identification including their social security card, driver’s license, or photo ID.
References should be checked out thoroughly. Prospective employees should provide the employer with names, dates of employment, and phone numbers of previous employers and how to contact them. It is best to talk directly to previous employers, rather than just to accept letters of recommendations. Also ask the applicant to provide or sign off on conducting a criminal background check

Special Points to Consider

Make sure the person you are considering hiring knows how to carry out the tasks the elder care recipient requires, such as transferring the senior to and from a wheelchair or bed. Training may be available, but make sure the worker completes the training successfully before hiring him or her.

No one should be hired on a seven-day-a-week basis. Even the most dedicated employee will soon burn out. All employees need some time to take care of their personal needs. No worker should be on call 24-hours a day. If the elder care recipient needs frequent supervision or care during the night, a family member or second home health care worker should be able to help out or fill in.

Live-in assistance may seem to be more convenient and economic than hourly or per-day employees but there can be drawbacks. Food and lodging costs must be calculated into the total cost of care, and it could be difficult to dismiss someone without immediate housing alternatives. If you decide to utilize a live-in arrangement, the employee should have his own living quarters, free time, and ample sleep.

Job Expectations and Considerations

Before hiring a senior home health care worker, you should go over the tasks you expect them to perform and other issues, such as promptness, benefits, pay scale, holidays, vacations, absences, and notification time needed for either employer or employee before employment is terminated. If you work and are heavily dependent on the home health care worker, emphasize the importance of being informed as soon as possible if he or she is going to be late or absent so that you can make alternative arrangements. Be clear about notification needed for time off, or what to do in the case the home health care worker experiences a personal emergency that requires them to abruptly leave work. It is important to have a backup list of friends, family, other home care workers, or a home health care agency you can call on.

Be clear about issues concerning salary, payment schedule, and reimbursement or petty cash funds for out of pocket expenses.

You should spend the day with the home health care worker on his first day to make sure you are both in agreement over how to carry out daily tasks. It would also be helpful to supply the home health care worker with a list of information on the elder care recipient such as: special diets, likes, dislikes, mobility problems, health issues, danger signs to monitor, possible behavior problems and accompanying coping strategies, medication schedule, therapeutic exercises, eye glasses, dentures, and any prosthetics.

You should also provide the following information to your home health care worker: your contact information, emergency contacts, security precautions and access to keys, clothing, and locations of washing/cleaning supplies, medical supplies, light bulbs, flashlights, fuse box, and other important household items.

Transportation

Another big consideration in hiring a senior home care worker is how he or she is going to get to work. If they do not have a reliable car or access to public transit, then you might want to consider hiring someone to drive him or her, which might be more economical than using taxis. Inform your insurance company if the home health care worker is going to drive your car when caring for the senior. Your insurance company will perform the necessary driving background checks. If the home health care worker is using his or her car to drive the elder care recipient, then discuss use of her or his car, and conduct a driving background check.

Insurance and Payroll

Check with an insurance company about the proper coverage for a worker in your home.

Make sure all the proper taxes are being drawn from the employee’s check by contacting the Internal Revenue Service, state treasury department, social security, and the labor department. If you do not want to deal with the complexities of the payroll withholdings yourself, than you can hire a payroll company for a fee.

Even if your home health care worker is working as a contractor, you are still obligated to report the earnings to the IRS. Talk to your accountant or financial adviser about making sure you are following IRS rules.

Ensuring Security

You should protect your private papers and valuables in a locked file cabinet, safe deposit box, or safe. If you are unable to pick up your mail on a daily basis, have someone you trust do it, or have it sent to a post box. You should check the phone bill for unusual items or unauthorized calls. You should put a block on your phone for 900 numbers, collect calls, and long-distance calls.

Keep checkbooks and credit cards locked up. Review credit card and bank statements on a monthly basis, and periodically request credit reports from credit reporting agencies. Lock up valuable possessions or keep an inventory of items accessible to people working in the house.

You can help to prevent elder abuse to your loved one by:

Make sure the home health care worker thoroughly understands his or her responsibilities, the elder care recipient’s medical problems and limitations, and how to cope with stressful situations.
Do not overburden the home health care worker.
Encourage openness over potential problems.
The following are possible signs of elder abuse or neglect:
Personality changes
Crying, whimpering, or refusing to talk
Sloppy appearance
Poor personal hygiene
Disorganized or dirty living conditions
Signs of inappropriate sedation, such as confusion, or excessive sleeping
Mysterious bruises, pressure sores, fractures, or burns
Weight loss
If you suspect abuse, act immediately. Do not wait until the situation turns tragic. Investigate the situation by talking to the elder care recipient in a safe situation, or install monitoring equipment. Examples of abusive behavior include yelling, threatening, or over controlling behavior that could involve isolating the senior from others. If the situation is serious, you should replace the home health care worker as quickly as possible. If you fear the elder care recipient is in danger, he or she should be separated from the home health care worker as soon as possible. Place the elder care recipient with a trusted relative or in a respite care facility. Make sure your loved one is safe before confronting the home health care worker, especially if there is concern about retaliation.
Report the situation to Adult Protective Services after ensuring the safety of the elder care recipient. The police should be contacted in the case of serious neglect, such as sexual abuse, physical injury, or misuse of funds.

Supervising a Home Health Care Worker

The most important thing to remember after hiring a home health care worker is to keep the lines of communication open. You should explain the job responsibilities clearly, and your responsibilities to the home health care worker. Do not forget that the home health care worker is there for the elder care recipient and not the rest of the family. For live-in arrangements, the maximum amount of privacy should be set up for the home health care worker’s living quarters. Meetings should be set up on a regular basis to assure that problems are nipped in the bud. If conflicts cannot be resolved after repeated attempts, than it is best to terminate the employee. In such a case, you may have to either place the elder care recipient in a nursing home temporarily or hire a home health care worker through an agency. Reserve funds should be kept on hand in the case of such an emergency.

General Eligibility Requirements for Home Care Benefits

Hiring a home health care worker directly is usually less expensive than hiring through a home health care agency; but if the elder care recipient is eligible and you wish to use assistance from Medicare, you must hire someone through a certified home health care agency. For the senior patient to be eligible, three or more services must be ordered by a physician. Other factors or eligibility are the required need for skilled nursing assistance, or one of the following therapies: physical, speech or occupational. The elder care recipient’s medical needs will determine asset and income requirements.

Hiring Home Health Care Workers through Home Health Care Agencies versus Independently

Different health professionals can assess the elder care recipient’s needs. A nurse or social worker can help with design and coordination of a home care plan. Your care manager, doctor, or discharge planner can help with services being covered by Medicare. They generally help make the arrangements with a home care agency.

You should ask the home health care agency how they supervise their employees, and what kind of training their employees receive. Find out the procedures for when an employee does not show up. Also ask about the fee schedule and what it covers, there may be a sliding fee schedule. Furthermore, find out if they have a policy for minimum or maximum hours. Ask the agency if there are any limitations on the types of tasks performed.

Especially if you have to pay for the care services yourself, find out if there are any hidden costs such as transportation. If all the costs for hiring a care worker through an agency become too much, you may want to consider hiring directly.

Hiring independent home health care workers is not only more economical than using an agency, but it also allows more direct control over the elder care.

Health Care Reform – Busting The 3 Biggest Myths Of ObamaCare

In the last few months we’ve seen a lot of Health Care Reform rules and regulations being introduced by the Health and Human Services Department. Every time that happens, the media gets hold of it and all kinds of articles are written in the Wall Street Journal, the New York Times, and the TV network news programs talk about it. All the analysts start talking about the pros and cons, and what it means to businesses and individuals.

The problem with this is, many times one writer looked at the regulation, and wrote a piece about it. Then other writers start using pieces from that first article and rewriting parts to fit their article. By the time the information gets widely distributed, the actual regulations and rules get twisted and distorted, and what actually shows up in the media sometimes just doesn’t truly represent the reality of what the regulations say.

There’s a lot of misunderstanding about what is going on with ObamaCare, and one of the things that I’ve noticed in discussions with clients, is that there’s an underlying set of myths that people have picked up about health care reform that just aren’t true. But because of all they’ve heard in the media, people believe these myths are actually true.

Today we’re going to talk about three myths I hear most commonly. Not everybody believes these myths, but enough do, and others are unsure what to believe, so it warrants dispelling these myths now.

The first one is that health care reform only affects uninsured people. The second one is that Medicare benefits and the Medicare program isn’t going to be affected by health care reform. And then the last one is that health care reform is going to reduce the costs of healthcare.

Health Care Reform Only Affects Uninsured

Let’s look at the first myth about health care reform only affecting uninsured people. In a lot of the discussions I have with clients, there are several expressions they use: “I already have coverage, so I won’t be affected by ObamaCare,” or “I’ll just keep my grandfathered health insurance plan,” and the last one – and this one I can give them a little bit of leeway, because part of what they’re saying is true — is “I have group health insurance, so I won’t be affected by health care reform.”

Well, the reality is that health care reform is actually going to affect everybody. Starting in 2014, we’re going to have a whole new set of health plans, and those plans have very rich benefits with lots of extra features that the existing plans today don’t offer. So these new plans are going to be higher cost.

Health Care Reform’s Effect On People With Health Insurance

People that currently have health insurance are going to be transitioned into these new plans sometime in 2014. So the insured will be directly affected by this because the health plans they have today are going away, and they will be mapped into a new ObamaCare plan in 2014.

Health Care Reform Effect On The Uninsured

The uninsured have an additional issue in that if they don’t get health insurance in 2014, they face a mandate penalty. Some of the healthy uninsured are going to look at that penalty and say, “Well, the penalty is 1% of my adjusted gross income; I make $50,000, so I’ll pay a $500 penalty or $1,000 for health insurance. In that case I’ll just take the penalty.” But either way, they will be directly affected by health care reform. Through the mandate it affects the insured as well as the uninsured.

Health Care Reform Effect On People With Grandfathered Health Plans

People that have grandfathered health insurance plans are not going to be directly affected by health care reform. But because of the life cycle of their grandfathered health plan, it’s going to make those plans more costly as they discover that there are plans available now that they can easily transfer to that have a richer set of benefits that would be more beneficial for any chronic health issues they may have.

For people who stay in those grandfathered plans, the pool of subscribers in the plan are going to start to shrink, and as that happens, the cost of those grandfathered health insurance plans will increase even faster than they are now. Therefore, people in grandfathered health plans will also be impacted by ObamaCare.

Health Care Reform Effect On People With Group Health Insurance

The last one, the small group marketplace, is going to be the most notably affected by health care reform. Even though the health care reform regulations predominantly affect large and medium-sized companies, and companies that have 50 or more employees, smaller companies will also be affected, even though they’re exempt from ObamaCare itself.

What many surveys and polls are starting to show is that some of the businesses that have 10 or fewer employees are going to look seriously at their option to drop health insurance coverage altogether, and no longer have it as an expense of the company. Instead, they will have their employees get health insurance through the health insurance exchanges.

In fact, some of the carriers are now saying they anticipate that up to 50% of small groups with 10 or fewer employees are going to drop their health insurance plan sometime between 2014 and 2016. That will have a very large effect on all people who have group health insurance, especially if they’re in one of those small companies that drop health insurance coverage.

It’s not just uninsured that are going to be affected by health care reform, everybody is going to be impacted.

Health Care Reform Will Not Affect Medicare

The next myth was that health care reform would not affect Medicare. This one is kind of funny because right from the very get-go, the most notable cuts were specifically targeting the Medicare program. When you look at Medicare’s portion of the overall federal, you can see that in 1970, Medicare was 4% of the U.S. federal budget, and by 2011, it had grown to 16% of the federal budget.

If we look at it over the last 10 years, from 2002 to 2012, Medicare is the fastest growing part of the major entitlement programs in the federal government, and it’s grown by almost 70% during that period of time.

Because of how large Medicare is and how fast it’s growing, it’s one of the key programs that ObamaCare is trying to get a handle on, so it doesn’t bankrupts the U.S. Medicare is going to be impacted, and in fact the initial cuts to Medicare have already been set at about $716 billion.

Medicare Advantage Cuts And The Effects

Of that $716 billion cut, the Medicare Advantage program gets cut the most, and will see the bulk of the effects. What that’s going to do is increase the premiums people pay for their Medicare Advantage plans, and reduce the benefits of those plans.

Increased Medicare Advantage Costs

Right now, many people choose Medicare Advantage plans because they have zero premium. When given a choice on Medicare plans, they view it as an easy choice because it’s a free program for them, “Sure, I get Medicare benefits, I don’t pay anything for it; why not.” Now they’re going to see Medicare premiums start to climb, and go from zero to $70, $80, $90, $100. We’ve already seen that with some of the Blue Cross Medicare Advantage plans this year. It’s going to get worse as we go forward in the future.

Reduced Medicare Advantage Benefits

In order to minimize the premium increases, what many Medicare Advantage plans will do is increase the copayments, increase the deductibles, and change the co-insurance rates. In order to keep the premiums down, they’ll just push more of the costs onto the Medicare Advantage recipients. Increased premiums and reduced benefits are what we’re going to see coming in Medicare Advantage plan.

Fewer Medicare Physicians

And then if that wasn’t bad enough, as Medicare doctors begin receiving lower and lower reimbursements for Medicare Advantage people, they’re going to stop taking new Medicare Advantage recipients. We’re going to see the pool of doctors to support people in Medicare starting to shrink as well, unless changes are made over the course of the next five years. So Medicare is going to be affected, and it’s going to be affected dramatically by health care reform. Everybody’s kind of on pins and needles, waiting to see what’s going to happen there.

Health Care Reform Will Reduce Healthcare Costs

The last one, and probably the biggest myth about health care reform, is everybody thinking that ObamaCare will reduce healthcare costs. That’s completely hogwash. Early on in the process, when they were trying to come up with the rules and regulations, the emphasis and one of the goals for reform was to reduce healthcare costs.

But somewhere along the line, the goal actually shifted from cost reduction to regulation of the health insurance industry. Once they made that transition, they pushed cost reductions to the back burner. There are some small cost reduction components in ObamaCare, but the real emphasis is on regulating health insurance. The new plans, for example, have much richer benefits than many plans today: richer benefits means richer prices.

Health Care Reform Subsidies: Will They Make Plans Affordable?

A lot of people hope, “The subsidies are going to make health insurance plans more affordable, won’t they?” Yes, in some cases the subsidies will help to make the plans affordable for people. But if you make $1 too much, the affordable plans are suddenly going to become very expensive and can cost thousands of dollars more over the course of a year. Will a subsidy make it affordable or not affordable is really subject to debate at this point in time. We’re going to have to actually see what the rates look like for these plans.

New Health Care Reform Taxes Passed On To Consumers

Then there’s a whole ton of new health care reform taxes that have been added into the system to help pay for ObamaCare. That means everybody who has a health insurance plan, whether it’s in a large group, a small group, or just as an individual, is going to be taxed in order to pay for the cost of reform. Health care reform adds various taxes on health care that insurance companies will have to collect and pay, but they’re just going to pass it right through to us, the consumer.

Mandate Won’t Reduce Uninsured Very Much

During the initial years of health care reform, the mandate is actually pretty weak. The mandate says that everyone must get health insurance or pay a penalty (a tax). What that’s going to do is make healthy people just sit on the sidelines and wait for the mandate to get to the point where it finally forces them to buy health insurance. People with chronic health conditions that couldn’t get health insurance previously, are all going to jump into healthcare at the beginning of 2014.

At the end of that year, the cost for the plans is going to go up in 2015. I can guarantee that that’s going to happen, because the young healthy people are not going to be motivated to get into the plans. They won’t see the benefit of joining an expensive plan, whereas the chronically ill people are going to get into the plans and drive the costs up.

Health Care Reform’s Purpose Is Just A Matter Of Semantics

The last portion of this is, one of the key things – and it’s funny, I saw it for the first two years, 2010, and ’11 – one of the key things that was listed in the documentation from the Obama administration was: Health Care Reform would help reduce the cost that we would see in the future if we do nothing today. That was emphasized over and over again. That was how they presented health care cost reduction, that it would reduce the future costs. Not today, but it would reduce what we would pay in the future if we did nothing about it now.

Well, that’s great, 10 years from now we’re going to pay less than we might have paid. And we all know how accurate future projections usually are. In the meantime, we’re all paying more today, and we’re going to pay even more in 2014 and more in 2015 and 2016. People are going to be pretty upset about that.

Conclusion

Those three myths, that health care reform is only going to affect the uninsured, that it won’t affect Medicare beneficiaries, and that ObamaCare is going to reduce healthcare costs, are just that. They are myths. There’s nothing to them.

It’s really important that you pay attention to what’s happening with health care reform, because there are more changes that are coming as we go through this year, 2013. Knowing how to position yourself so that you’re in the right spot to be able to make the best decision at the beginning of 2014 is going to be really important for everybody.

Tim Thompson is the founder of SPF Insurance Services in San Diego, CA and has been writing about insurance topics for over 10 years. http://spfinsurance.com

At SPF Insurance we are your Health Care Reform experts in California. Sign up for our newsletter at the SPF Insurance website to stay updated on changes, or you can subscribe to the SPFInsurance YouTube channel to get our video updates, or you can sign up for our podcasts and see the updates through iTunes. Any of these will keep you up-to-date on what’s happening, and in particular, how it will affect you.

A Socialized Health Care System Requires Population Control and Impeccable Registries

In a nationalized health care system, you need to know who is who – otherwise the system could never be able determine who is entitled. The structure depends on how the system is created and designed, but with a nationalized health care system you will be tracked by the state where you reside and how you move in a manner that is unseen in America. The nationalized health care system becomes a vehicle for population control.

If you leave the United States and are no longer a resident of the state, even if you are a citizen and might maintain a driving license, you will have to report immediately if you want to avoid the 13% health care tax. I use the number 13% as it is in Sweden to exemplify the actual tax pressure that is laid upon you for the nationalized health care.

Let’s say you moved and you do not want to pay the 13% tax for services you do not receive, can receive, or want to taken out from the tax roll. The mammoth entity has no interest to let you go so easy. You will end up having to reveal your private life – partner, dwellings, travel, money, and job to prove your case that you have the right to leave the public health care system and do not need to pay the tax. If you have to seek an appeal, your information could be a part of administrative court documents that are open and public documents. As soon as you return to the United States, you will be automatically enrolled again and the taxes start to pile up.

Public universal health care has no interest in protecting your privacy. They want their tax money and, to fight for your rights, you will have to prove that you meet the requirements to not be taxable. In that process, your private life is up for display.

The national ID-card and national population registry that includes your medical information is a foundation of the nationalized health care system. You can see where this is going – population control and ability to use the law and health care access to map your whole private life in public searchable databases owned and operated by the government.

By operating an impeccable population registry that tracks where you live, who you live with, when you move and your citizen status including residency the Swedes can separate who can receive universal health care from those not entitled. The Swedish authorities will know if you have a Swedish social security number, with the tap of the keyboard, more information about yourself than you can remember. The Swedish government has taken sharing of information between agencies to a new level. The reason is very simple – to collect health care tax and suppress any tax evasion.

It is heavily centralized and only the central administration can change the registered information in the data. So if you want to change your name, even the slightest change, you have to file an application at a national agency that processes your paperwork. This centralized population registry makes it possible to determine who is who under all circumstances and it is necessary for the national health care system. Otherwise, any person could claim to be entitled.

To implement that in the United States requires a completely new doctrine for population registry and control. In an American context that would require that every existing driving license had to be voided and reapplied under stricter identification rules that would match not only data from Internal Revenue Service, state government, municipal government, Social Security Administration, and Department of Homeland Security but almost any agency that provides services to the general public. The reason why a new population registry would be needed in the United States is the fact that lax rules dating back to the 1940s up until the War on Terrorism, and stricter identification criteria following 9/11, has made a significant percentage of personal information about individuals questionable.

If America instead neglects maintaining secure records, determining eligibility for public health care would not be possible and the floodgates for fraud would open and rampant misuse of the system would prevail. This would eventually bring down the system.

It is financially impossible to create a universal health care system without clearly knowing who is entitled and not. The system needs to have limits of its entitlement. A social security number would not be enough as these numbers have been handed out through decades to temporary residents that might not even live in the United States or might today be out of status as illegal immigrants.

The Congress has investigated the cost of many of the “public options”, but still we have no clear picture of the actual realm of the group that would be entitled and under which conditions. The risk is political. It is very easy for political reasons to extend the entitlement. Politicians would have a hard time being firm on illegal immigrants’ entitlement, as that would put the politicians on a collision course with mainly the Hispanic community as they represent a significant part of the illegal immigrants. So the easy sell is then that everyone that is a legal resident alien or citizen can join according to one fee plan and then the illegal immigrants can join according to a different fee structure. That assumes that they actually pay the fee which is a wild guess as they are likely to be able to get access to service without having to state that they are illegal immigrants.

It would work politically – but again – without an impeccable population registry and control over who is who on a national level, this is unlikely to succeed. The system would be predestined to fail because of lack of funds. If you design a system to provide the health care needs for a population and then increase that population without any additional funds – then naturally it would lead to a lower level of service, declined quality, and waiting lists for complex procedures. In real terms, American health care goes from being a first world system to a third world system.

Thousands, if not a million, American residents live as any other American citizen but they are still not in good standing with their immigration even if they have been here for ten or fifteen years. A universal health care system will raise issues about who is entitled and who is not.

The alternative is for an American universal health care system to surrender to the fact that there is no order in the population registry and just provide health care for everyone who shows up. If that is done, costs will dramatically increase at some level depending on who will pick up the bill – the state government, the federal government, or the public health care system.

Illegal immigrants that have arrived within the last years and make up a significant population would create an enormous pressure on a universal health care, if implemented, in states like Texas and California. If they are given universal health care, it would be a pure loss for the system as they mostly work for cash. They will never be payees into the universal health care system as it is based on salary taxes, and they do not file taxes.

The difference is that Sweden has almost no illegal immigrants compared to the United States. The Swedes do not provide health care services for illegal immigrants and the illegal immigrants can be arrested and deported if they require public service without good legal standing.

This firm and uniform standpoint towards illegal immigration is necessary to avoid a universal health care system from crumbling down and to maintain a sustainable ratio between those who pay into the system and those who benefit from it.

The working middle class that would be the backbone to pay into the system would not only face that their existing health care is halved in its service value – but most likely face higher cost of health care as they will be the ones to pick up the bill.

The universal health care system would have maybe 60 million to 70 million “free riders” if based on wage taxes, and maybe half if based on fees, that will not pay anything into the system. We already know that approximately 60 million Americans pay no taxes as adults add to that the estimated 10-15 million illegal immigrants.

There is no way that a universal health care system can be viably implemented unless America creates a population registry that can identify the entitlements for each individual and that would have to be designed from scratch to a high degree as we can not rely on driver’s license data as the quality would be too low – too many errors.

Many illegal immigrants have both social security numbers and driver’s licenses as these were issued without rigorous control of status before 9/11. The alternative is that you had to show a US passport or a valid foreign passport with a green card to be able to register.

Another problematic task is the number of points of registration. If the registration is done by hospitals – and not a federal agency – then it is highly likely that registration fraud would be rampant. It would be very easy to trespass the control of eligibility if it is registered and determined by a hospital clerk. This supports that the eligibility has to be determined by a central administration that has a vast access to data and information about our lives, income, and medical history. If one single registration at a health care provider or hospital would guarantee you free health care for life and there is no rigorous and audited process – then it is a given that corruption, bribery, and fraud would be synonymous with the system.

This requires a significant level of political strength to confront and set the limits for who is entitled – and here comes the real problem – selling out health care to get the votes of the free riders. It is apparent that the political power of the “free” health care promise is extremely high.

A promise that can not alienate anyone as a tighter population registry would upset the Hispanic population, as many of the illegal immigrants are Hispanics – and many Hispanics might be citizens by birth but their elderly parents are not. Would the voting power of the younger Hispanics act to put pressure to extend health care to elderly that are not citizens? Yes, naturally, as every group tries to maximize its own self-interest.

The risk is, even with an enhanced population registry, that the group of entitled would expand and put additional burden on the system beyond what it was designed for. That could come though political wheeling and dealing, sheer inability from an administrative standpoint to identify groups, or systematic fraud within the system itself.

We can speculate about the outcome but the challenges are clear. This also represents a new threat to the privacy and respect for the private sphere of the citizenry as an increased population registration and control empowers the government with more accurate information about our lives and the way we live our lives. Historically, has any government when given the opportunity to get power taken that opportunity and given that power back to the people after the initial objective was reached? Governments like to stick to power.

To ensure the universal health care system is designed to function as intended it, would require procedures that would limit fraud, amass a significant amount of personal information, have access to all your medical data, and also determine who you are beyond any doubt. Just to be able to determine if you are entitled or not and, track the expenditures you generate.

The aggregation of these data could also open the floodgates for any data mining within these data under the pure excuse that it would help the universal health care system to better “serve you” and lower the costs.

To lower the costs also means to identify which procedures should not be done on which type of patients as it is not viable based on the government’s interest to optimize your productivity under your life cycle. The collection of data has a tendency to look inviting and good when we start to collect it but aggregated data and personal information creates a deep intrusion in our privacy.

Hospital Leadership, Strategy, And Culture In The Age of Health Care Reform

With just eleven months to go before the Value-Based Purchasing component of the Affordable Care Act is scheduled to go into effect, it is an auspicious time to consider how health care providers, and hospitals specifically, plan to successfully navigate the adaptive change to come. The delivery of health care is unique, complex, and currently fragmented. Over the past thirty years, no other industry has experienced such a massive infusion of technological advances while at the same time functioning within a culture that has slowly and methodically evolved over the past century. The evolutionary pace of health care culture is about to be shocked into a mandated reality. One that will inevitably require health care leadership to adopt a new, innovative perspective into the delivery of their services in order to meet the emerging requirements.

First, a bit on the details of the coming changes. The concept of Value-Based Purchasing is that the buyers of health care services (i.e. Medicare, Medicaid, and inevitably following the government’s lead, private insurers) hold the providers of health care services accountable for both cost and quality of care. While this may sound practical, pragmatic, and sensible, it effectively shifts the entire reimbursement landscape from diagnosis/procedure driven compensation to one that includes quality measures in five key areas of patient care. To support and drive this unprecedented change, the Department of Health and Human Services (HHS), is also incentivizing the voluntary formation of Accountable Care Organizations to reward providers that, through coordination, collaboration, and communication, cost-effectively deliver optimum patient outcomes throughout the continuum of the health care delivery system.

The proposed reimbursement system would hold providers accountable for both cost and quality of care from three days prior to hospital admittance to ninety days post hospital discharge. To get an idea of the complexity of variables, in terms of patient handoffs to the next responsible party in the continuum of care, I process mapped a patient entering a hospital for a surgical procedure. It is not atypical for a patient to be tested, diagnosed, nursed, supported, and cared for by as many as thirty individual, functional units both within and outside of the hospital. Units that function and communicate both internally and externally with teams of professionals focused on optimizing care. With each handoff and with each individual in each team or unit, variables of care and communication are introduced to the system.

Historically, quality systems from other industries (i.e. Six Sigma, Total Quality Management) have focused on wringing out the potential for variability within their value creation process. The fewer variables that can affect consistency, the greater the quality of outcomes. While this approach has proven effective in manufacturing industries, health care presents a collection of challenges that go well beyond such controlled environments. Health care also introduces the single most unpredictable variable of them all; each individual patient.

Another critical factor that cannot be ignored is the highly charged emotional landscape in which health care is delivered. The implications of failure go well beyond missing a quarterly sales quota or a monthly shipping target, and clinicians carry this heavy, emotional burden of responsibility with them, day-in and day-out. Add to this the chronic nursing shortage (which has been exacerbated by layoffs during the recession), the anxiety that comes with the ambiguity of unprecedented change, the layering of one new technology over another (which creates more information and the need for more monitoring), and an industry culture that has deep roots in a bygone era and the challenge before us comes into greater focus.

Which brings us to the question; what approach should leadership adopt in order to successfully migrate the delivery system through the inflection point where quality of care and cost containment intersect? How will this collection of independent contractors and institutions coordinate care and meet the new quality metrics proposed by HHS? The fact of the matter is, health care is the most human of our national industries and reforming it to meet the shifting demographic needs and economic constraints of our society may prompt leadership to revisit how they choose to engage and integrate the human element within the system.

In contemplating this approach, a canvasing of the peer-reviewed research into both quality of care and cost containment issues points to a possible solution; the cultivation of emotional intelligence in health care workers. After reviewing more than three dozen published studies, all of which confirmed the positive impact cultivating emotional intelligence has in clinical settings, I believe contemplating this approach warrants further exploration.

Emotional intelligence is a skill as much as an attribute. It is comprised by a set of competencies in Self-Awareness, Self Management, Social Awareness, and Relationship Management, all leading to Self Mastery. Fortunately, these are skills that can be developed and enhanced over the course of one’s lifetime.

Keeping the number of handoffs and individuals involved in delivering the continuum of care, let’s examine how emotional intelligence factors into the proposed quality measures the Department of Health and Human Services will be using come October, 2012:

1.) Patient/Caregiver Experience of Care – This factor really comes down to a patient’s perception of care. Perceptions of care are heavily shaded by emotions. Patients consistently rate less skilled surgeons that have a greater bedside manner as better than maestro surgeons that lack, or choose not to display, these softer skills. Additional research into why people sue over malpractice also indicates how perceptions of care are formed. People don’t sue over a medical mistake in and of itself. People sue because of how they felt they were treated after the error occurred. From the patient’s perspective (and often their family’s) there’s a difference between being cured and being healed. The difference often can be found in the expression of authentic empathy through healthy, professional boundaries.

This is a key driver in patient decision-making as well. Patients tend to choose a hospital based upon one or two criteria; the recommendation of their primary care physician (with whom they have an established relationship) and/or upon the recommendations from family members or friends that have experienced care in a particular hospital or an individual surgeon. A quick look into the field of Applied Behavioral Economics supports this finding. Economic decision making is 70% emotionally driven with the remaining 30% based in rational thought. In many instances, it would appear that a lot of hospital marketing initiatives don’t seem to reflect an understanding of this phenomena. Waiting room times in Emergency Rooms have little to do with why patients choose a hospital, yet we see billboards everywhere that have the actual E.R. wait times electronically flashing along the roadside.

A patient’s experience (and perception) of care can be highly impacted at the handoff points within the continuum of care. Any new model of care will require exceptional cross-organizational communications to emerge. This requires a high level of engagement and commitment to the new vision at every patient touch-point.

This metric also addresses the caregivers’ experience of care. This speaks largely to the experience of nurses that are delivering that care. The research related to the impact of cultivating emotional intelligence in nurses clearly demonstrates a reduction in stress, improved communication skills, improved leadership and retention, the ability to quickly connect and engage patients, as well as a reduction in nurse burnout (which leads to turnover and additional stress amongst the remaining staff).

2.) Care Co-ordination – Again, this will require optimal engagement and pro-active communication intra-organizationally and cross-organizationally. Each handoff introduces opportunities for variable care to emerge that must be seamlessly co-ordinated. Poor co-ordination also introduces the risk of eroding the quality of the patient’s experience.

3.) Patient Safety – Research shows that the cultivation of emotional intelligence competencies in nursing contributes to positive patient outcomes, lowers the risk of adverse events, lowers costs at discharge, and reduces medication errors, all while lowering nurse stress, burnout, and turnover. Each time a nurse resigns it adds to the nursing shortage on the floor, requires additional hours from other nurses, and costs the hospital approximately $64,000, on average, to backfill the open position. Improving how an institution cares for its nurses improves the level of patient care and safety as well. In many institutions, this will require a shift in leadership’s perspective in order to support a culture that embraces and values the critical role nurses play in maintaining patient safety.

4.) Preventive Health – Elevating Self-Awareness and Social Awareness in clinicians helps them quickly connect and effectively communicate with patients. Subtle, non-verbal cues become more readily apparent, helping clinicians understand the fears and emotions of their patients. Self Management and Relationship Management helps clinicians communicate appropriately and supports the expression of authentic empathy through healthy, professional boundaries. All of these factors come into play when speaking with patients about lifestyle choices, course of treatment, and preventive health care.

From our own personal lives we’ve all learned we cannot “fix” other peoples’ behaviors. We can, however, be in relationship and help support healthy changes they’re ready to embrace. Pro-actively moving to improve preventive health will require deeper, more authentic relationships to emerge between front-line health care providers and patients.

5.) At-Risk Population/Frail Elderly Health – Like preventive health, being measured on the care of the community’s at-risk population and elderly will require an innovative approach to community outreach and pro-active communication. These are not populations that can be easily reached via Facebook or Twitter. Building effective relationships with these demographics will require trustful, human contact and deep engagement with each population, both of which are supported through the development of a mindful approach (i.e. emotionally intelligent) to the challenges at hand.

It will be interesting to see how reform unfolds and how leadership within the health care delivery system chooses to respond to the challenges that lie ahead. Systems and hospitals that choose to take an honest, evidence-based look at how they choose to lead, how they create and execute strategy, and the organizational culture they’re cultivating will be well served in preparing to successfully navigate this unprecedented change.

© 2011, Terry Murray.

Terry Murray is a professional coach and business executive with twenty-five years of progressive experience in strategic development, executive leadership, and the deployment of highly profitable business teams. His executive leadership with Fortune 1000 and start-up companies has directly contributed more than $1 billion in market capitalization growth throughout his career.

Terry is the founder and president of Performance Transformation, LLC a Professional Coaching and Strategic Development firm focused on igniting breakthrough performance through the authentic engagement and development of human talent. The company’s evidence-based programs and philosophical approach employs their proprietary Adaptive Coaching Process. The organization’s engagements align the clients’ human capital with their strategic imperatives driving tangible results, delivering a sustainable competitive advantage and an exceptional Return on Investment.

Patient Abandonment – Home Health Care

Elements of the Cause of Action for Abandonment

Each of the following five elements must be present for a patient to have a proper civil cause of action for the tort of abandonment:

1. Health care treatment was unreasonably discontinued.

2. The termination of health care was contrary to the patient’s will or without the patient’s knowledge.

3. The health care provider failed to arrange for care by another appropriate skilled health care provider.

4. The health care provider should have reasonably foreseen that harm to the patient would arise from the termination of the care (proximate cause).

5. The patient actually suffered harm or loss as a result of the discontinuance of care.

Physicians, nurses, and other health care professionals have an ethical, as well as a legal, duty to avoid abandonment of patients. The health care professional has a duty to give his or her patient all necessary attention as long as the case required it and should not leave the patient in a critical stage without giving reasonable notice or making suitable arrangements for the attendance of another. [2]

Abandonment by the Physician

When a physician undertakes treatment of a patient, treatment must continue until the patient’s circumstances no longer warrant the treatment, the physician and the patient mutually consent to end the treatment by that physician, or the patient discharges the physician. Moreover, the physician may unilaterally terminate the relationship and withdraw from treating that patient only if he or she provides the patient proper notice of his or her intent to withdraw and an opportunity to obtain proper substitute care.

In the home health setting, the physician-patient relationship does not terminate merely because a patient’s care shifts in its location from the hospital to the home. If the patient continues to need medical services, supervised health care, therapy, or other home health services, the attending physician should ensure that he or she was properly discharged his or her-duties to the patient. Virtually every situation ‘in which home care is approved by Medicare, Medicaid, or an insurer will be one in which the patient’s ‘needs for care have continued. The physician-patient relationship that existed in the hospital will continue unless it has been formally terminated by notice to the patient and a reasonable attempt to refer the patient to another appropriate physician. Otherwise, the physician will retain his or her duty toward the patient when the patient is discharged from the hospital to the home. Failure to follow through on the part of the physician will constitute the tort of abandonment if the patient is injured as a result. This abandonment may expose the physician, the hospital, and the home health agency to liability for the tort of abandonment.

The attending physician in the hospital should ensure that a proper referral is made to a physician who will be responsible for the home health patient’s care while it is being delivered by the home health provider, unless the physician intends to continue to supervise that home care personally. Even more important, if the hospital-based physician arranges to have the patient’s care assumed by another physician, the patient must fully understand this change, and it should be carefully documented.

As supported by case law, the types of actions that will lead to liability for abandonment of a patient will include:

• premature discharge of the patient by the physician

• failure of the physician to provide proper instructions before discharging the patient

• the statement by the physician to the patient that the physician will no longer treat the patient

• refusal of the physician to respond to calls or to further attend the patient

• the physician’s leaving the patient after surgery or failing to follow up on postsurgical care. [3]

Generally, abandonment does not occur if the physician responsible for the patient arranges for a substitute physician to take his or her place. This change may occur because of vacations, relocation of the physician, illness, distance from the patient’s home, or retirement of the physician. As long as care by an appropriately trained physician, sufficiently knowledgeable of the patient’s special conditions, if any, has been arranged, the courts will usually not find that abandonment has occurred. [4] Even where a patient refuses to pay for the care or is unable to pay for the care, the physician is not at liberty to terminate the relationship unilaterally. The physician must still take steps to have the patient’s care assumed by another [5] or to give a sufficiently reasonable period of time to locate another prior to ceasing to provide care.

Although most of the cases discussed concern the physician-patient relationship, as pointed out previously, the same principles apply to all health care providers. Furthermore, because the care rendered by the home health agency is provided pursuant to a physician’s plan of care, even if the patient sued the physician for abandonment because of the actions (or inactions of the home health agency’s staff), the physician may seek indemnification from the home health provider. [6]

ABANDONMENT BY THE NURSE OR HOME HEALTH AGENCY

Similar principles to those that apply to physicians apply to the home health professional and the home health provider. A home health agency, as the direct provider of care to the homebound patient, may be held to the same legal obligation and duty to deliver care that addresses the patient’s needs as is the physician. Furthermore, there may be both a legal and an ethical obligation to continue delivering care, if the patient has no alternatives. An ethical obligation may still exist to the patient even though the home health provider has fulfilled all legal obligations. [7]

When a home health provider furnishes treatment to a patient, the duty to continue providing care to the patient is a duty owed by the agency itself and not by the individual professional who may be the employee or the contractor of the agency. The home health provider does not have a duty to continue providing the same nurse, therapist, or aide to the patient throughout the course of treatment, so long as the provider continues to use appropriate, competent personnel to administer the course of treatment consistently with the plan of care. From the perspective of patient satisfaction and continuity of care, it may be in the best interests of the home health provider to attempt to provide the same individual practitioner to the patient. The development of a personal relationship with the provider’s personnel may improve communications and a greater degree of trust and compliance on the part of the patient. It should help to alleviate many of the problems that arise in the health care’ setting.

If the patient requests replacement of a particular nurse, therapist, technician, or home health aide, the home health provider still has a duty to provide care to the patient, unless the patient also specifically states he or she no longer desires the provider’s service. Home health agency supervisors should always follow up on such patient requests to determine the reasons regarding the dismissal, to detect “problem” employees, and to ensure no incident has taken place that might give rise to liability. The home health agency should continue providing care to the patient until definitively told not to do so by the patient.

COPING WITH THE ABUSIVE PATIENT

Home health provider personnel may occasionally encounter an abusive patient. This abuse mayor may not be a result of the medical condition for which the care is being provided. Personal safety of the individual health care provider should be paramount. Should the patient pose a physical danger to the individual, he or she should leave the premises immediately. The provider should document in the medical record the facts surrounding the inability to complete the treatment for that visit as objectively as possible. Management personnel should inform supervisory personnel at the home health provider and should complete an internal incident report. If it appears that a criminal act has taken place, such as a physical assault, attempted rape, or other such act, this act should be reported immediately to local law enforcement agencies. The home care provider should also immediately notify both the patient and the physician that the provider will terminate its relationship with the patient and that an alternative provider for these services should be obtained.

Other less serious circumstances may, nevertheless, lead the home health provider to determine that it should terminate its relationship with a particular patient. Examples may include particularly abusive patients, patients who solicit -the home health provider professional to break the law (for example, by providing illegal drugs or providing non-covered services and equipment and billing them as something else), or consistently noncompliant patients. Once treatment is undertaken, however, the home health provider is usually obliged to continue providing services until the patient has had a reasonable opportunity to obtain a substitute provider. The same principles apply to failure of a patient to pay for the services or equipment provided.

As health care professionals, HHA personnel should have training on how to handle the difficult patient responsibly. Arguments or emotional comments should be avoided. If it becomes clear that a certain provider and patient are not likely to be compatible, a substitute provider should be tried. Should it appear that the problem lies with the patient and that it is necessary for the HHA to terminate its relationship with the patient, the following seven steps should be taken:

1. The circumstances should be documented in the patient’s record.

2. The home health provider should give or send a letter to the patient explaining the circumstances surrounding the termination of care.

3. The letter should be sent by certified mail, return receipt requested, or other measures to document patient receipt of the letter. A copy of the letter should be placed in the patient’s record.

4. If possible, the patient should be given a certain period of time to obtain replacement care. Usually 30 days is sufficient.

5. If the patient has a life-threatening condition or a medical condition that might deteriorate in the absence of continuing care, this condition should be clearly stated in the letter. The necessity of the patient’s obtaining replacement home health care should be emphasized.

6. The patient should be informed of the location of the nearest hospital emergency department. The patient should be told to either go to the nearest hospital emergency department in case of a medical emergency or to call the local emergency number for ambulance transportation.

7. A copy of the letter should be sent to the patient’s attending physician via certified mail, return receipt requested.

These steps should not be undertaken lightly. Before such steps are taken, the patient’s case should be thoroughly discussed with the home health provider’s risk manager, legal counsel, medical director, and the patient’s attending physician.

The inappropriate discharge of a patient from health care coverage by the home health provider, whether because of termination of entitlement, inability to pay, or other reasons, may also lead to liability for the tort of abandonment. [8]

Nurses who passively stand by and observe negligence by a physician or anyone else will personally become accountable to the patient who is injured as a result of that negligence… [H]ealthcare facilities and their nursing staff owe an independent duty to patients beyond the duty owed by physicians. When a physician’s order to discharge is inappropriate, the nurses will be help liable for following an order that they knew or should know is below the standard of care. [9]

Similar principles may apply to make the home health provider vicariously liable, as well.

Liability to the patient for the tort of abandonment may also result from the home health care professional’s failure to observe, examine, assess, or monitor a patient’s condition. [10] Liability for abandonment may arise from failing to take timely action, as well as failing to summon a physician when a physician is needed. [11] Failing to provide adequate staff to meet the patient’s needs may also constitute abandonment on the part of the HHA. [12] Ignoring a patient’s complaints and failing to follow a physician’s orders may likewise constitute a tort of abandonment for a nurse or other professional staff member.

1. Lee v. Dewbre, 362 S.W.2d 900 (Tex. Civ. App. 7th Dist. 1962).

2. Kattsetos v. Nolan, 368 A.2d 172 (Conn. 1976).

3. 61 AM. Jur. 2d, Physicians and Surgeons § 237 (1981).

4. See, e.g., Tripp v. Pate, 271 S.E.2d 407 (N.C. App. 1980).

5. Ricks v. Budge, 64 P.2d 208 (Utah 1937).

6. M.D. Nathanson, Home Healthcare Answer Book: Legal Issues for Providers 212 (1995).

7. See, generally, E.P. Burnzeig, The Nurse’s Liability for Malpractice (1981).

8. Sheryl Feutz-Harter, Nursing Caselaw Update: In appropriate Discharging of Patients, 2 J. Nursing L. 49 (1995).

9. Id., 53.

10. See, e.g., Pisel v. Stamford Hosp., 430 A.2d1 (Conn. 1980) (nurses were held liable for failing to monitor the condition of a patient).

11. See, e.g., Sanchez v. Bay General Hosp., 172 Cal. Rptr. 342 (Cal. App. 1981); Valdez v. Lyman-Roberts Hosp., Inc. 638 S.W. 2d 111 (Tex. 1982).

12. Czubinsky v. Doctors Hosp., 188 CAl. Rptr. 685 (1983).