Blog and Helpful Articles

What We’re Reading – Mandating COVID-19 Vaccinations: Employers Wrestle with Whether they Can and Should

We’ve touched lately on several issues of can vs. should in the workplace, primarily with regard to political expressions and even ending remote work.  The issue of vaccines is probably just as polarizing for employers and their workforce. This article explores several facets of the topic, raising perhaps more questions than answers.  Below is an overview of the issues to consider, which we know can differ between private and public employers.

Legally, can a private employer require vaccination? No easy answer.  The Civil Rights Act requires employers to provide religious accommodations to those with sincerely held religious beliefs that prevent them from receiving the vaccine. Next is the Americans with Disabilities Act (ADA) which requires an accommodation for those who claim to be unable to receive the COVID-19 vaccine because of an underlying medical condition that constitutes a disability.

The US Constitution may add heft to public employees’ refusal to receive a COVID vaccine, whose argument is that their rights to free exercise of religion and personal liberties make mandatory vaccination policies unconstitutional.  Unionized workplaces (or groups of employees) may be protected from mandatory vaccination in their union’s collective bargaining agreements.

The author reminds us to consult the EEOC, CDC and OSHA to determine whether employers can effectively accommodate employees who refuse to be vaccinated.  Of course, the type of business weighs into the decision:  is yours one that requires considerable interaction with the public, or one where even staff interactions with each other are infrequent or rare?

Many employers have indicated they will not mandate COVID vaccinations for various reasons, including safety concerns about the vaccine, liability if employees experience serious side effects and even employee morale.  While workers’ compensation policies would protect employers in some instances, a few states are considering legislation to protect employers from W/C claims resulting from mandatory vaccination.

We hope you’ll leave a comment and share in which direction your company is leaning:  mandatory vaccinations, heightened current safety measures (masks, disinfecting, social distancing, continued remote work), and/or strong encouragement to employees to choose vaccination.

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Free webinar on No-Pay RAP Rule for Home Health

Our colleagues at Imark Billing posted an excellent webinar on the “No-Pay RAP Rule;”  the handouts are here. As our clients know, CCG does not handle home health billing.  We refer clients to Imark, and Lynn Labarta in particular, for her expertise in this complex area.  Over the coming months, we will feature Lynn’s blogs and communications on our website so that our clients and readers have quick access to this important information.

For information about Imark’s services, please visit their website or call 1-888.370.3339 Ext. 101.

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What We’re Reading – Why aren’t more employers recognizing their workers?

Sometimes an article comes along that isn’t new but sheds a spotlight on an issue that it stops us in our tracks.  That was this article, which reminds us of information from the book, 1,001 Ways to Engage Employees.  It’s.On.My.Bookshelf. for goodness sake!  And yet, I’m probably in good company in neglecting employee recognition in the wake of COVID-stress and the new age of widespread remote work.  The author states that the pandemic has made it harder to recognize remote employees because we don’t see them and aren’t reminded about what they’ve accomplished.  Out of sight, out of mind. Seriously, how sad is that?

We’re reminded that the basic human need of being validated hasn’t changed.  In fact, our workers may be more hungry for validation because they feel lonely, working on their own, and to a great extent, they’re alienated and in a vacuum.  What we took for granted in a brick-and-mortar environment, when we stopped by to give a quick pat on the back or a short convo, voicing appreciation for a worker’s contribution, is something that needs to be planned in today’s revamped “workplace.”

The author reminded us that HR has to be intentional about recognizing remote workers and as talented as many managers are, let’s not assume they know what to do in this regard.  In fact, a 2019 survey revealed that 19% of the responding employers had no employee recognition policy – and that was before COVID!

Let’s end 2020 on a different note:  calling to mind and applauding the resilience of our workers; praising their dogged determination to stay productive and engaged despite all the turmoil, fear (there. I said it) and change this year; and stoking the hope that springs eternal that we’ll inch back to the old normal which, in retrospect, maybe wasn’t so bad after all.  And let’s resolve to do better at this in 2021 – pandemic or not – especially since remote work, in some form or fashion, is here to stay.

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$3.4 Million in Coronavirus Citations: Are You Next?

Since the start of the coronavirus pandemic through Thanksgiving, the U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) has issued citations for violations related to coronavirus.  As we all know, OSHA’s role is to assist employers in creating and maintaining a safe work environment for all workers.  The pandemic has, of course, taxed employers across the board as they deal with a whole host of issues.

The violations arose from 255 inspections and a quick view of the four organizations fined in Florida reveals similarity among the issues.  The majority of the citations are for violating Part 1920 of the OSHA code, Subpart 1 entitled Personal Protective Equipment and specifically, standard number 1910.134 entitled Respiratory Protection.

All employers should take a moment to review the employer requirements when respiratory protection is required.  It’s a safe bet that the 255 inspections would pale to the violations among the total number of employers across the country.

Standard 1910.134(c)(1) states, “In any workplace where respirators are necessary to protect the health of the employee or whenever respirators are required by the employer, the employer shall establish and implement a written respiratory protection program with worksite-specific procedures.” 

Lest anyone think that a respirator is one of those “buggy” looking goggle-mask things from sci-fi movies, this is just one type.  The CDC defines a respirator as: a personal protective device that is worn on the face or head and covers at least the nose and mouth. A respirator is used to reduce the wearer’s risk of inhaling hazardous airborne particles (including infectious agents), gases or vapors. Respirators, including those intended for use in healthcare settings, are certified by the CDC/NIOSH.

This means that employers need actual P&P for: respirator selection; medical evaluations for employees required to wear one; fit testing; cleaning, disinfecting, storing, etc.; training on hazards and respirator use; and for evaluating the effectiveness of respirator use.  Each of these components is defined in the regulations and as with any regulation, the company’s documentation of these actions is crucial to demonstrating compliance and avoiding sanctions.

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MRA & The New Patient Visit

In our years of reviewing charts, we’ve observed new PCP visits where the clinician assigns diagnoses based on the medications the patient is taking, adds them to the problem list and includes them in the assessment of the visit.  Let’s review some specific examples and the perils of this habit on new visits, especially in the absence of old medical records.

The patient is taking Metformin and the PCP diagnoses diabetes.  Some patients are good historians and can lay out the sequence of events surrounding the DM diagnosis.  It would behoove the PCP to capture as much of this history in the HPI as possible because, in all likelihood, the clinician does not have the necessary information with which to otherwise assess the condition.

  • Example #1:  Mrs. Smith takes ___mg of Metformin twice daily.  This was started two years ago by her prior PCP after two high A1Cs (8.3 and 7.6).  She tests her blood sugar daily and reports that fasting sugars usually average 130-150.  A fingerstick blood sugar in the office was 86.
  • Example #2:  Mr. Jones takes ___mg of Metformin twice daily.  He does not remember why or when the medication was started by his former PCP.  When asked if he is diabetic, he said he wasn’t sure.  Mr. Jones does not check his blood glucose, does not have a glucometer and has never been evaluated by an endocrinologist. A fingerstick blood sugar in the office was 86.

Even though the PCP does not have recent lab values with which to assess DM, Mrs. Smith’s diagnosis appears supported by statements about lab values leading to the diagnosis and the patient’s current monitoring habits.  In this case, it would be appropriate for the PCP to add DM to the assessment, order new labs and revisit the condition at the next appointment.

In Mr. Jones’s case, the evidence is not so clear-cut.  We know that providers may prescribe Metformin for diabetes management, and also for cases of pre-diabetes (ICD-10-CM code R73.03) or even weight loss, so it is not permissible to infer a diagnosis from a medication.  The best course of action is to request records from the former PCP – at a minimum, lab records – to establish the legitimacy of the diagnosis.

But what of Ms. Green, who tells her new PCP that she was diagnosed with diabetes many years ago and doesn’t remember when?  She takes no medication for it and when asked, cannot remember any other details concerning her self-reported diagnosis of DM.  She explains that her doctor at the time advised that she follow a low-carb diet and engage in regular aerobic exercise, which she continues to this day.  A fingerstick blood sugar in the office was 86.

In Ms. Green’s case, the PCP has little beyond “the patient said” to support the diagnosis of DM.  It’s advisable to obtain records from prior PCPs, specialists or labs in an effort to find supporting evidence of the condition.  “Per patient” conditions should be listed in the history and added to the assessment only when the PCP has evidence they are legitimate and has the ability to assess their status (e.g., recent lab or imaging evidence).

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What We’re Reading – Risk-based agreements: Good for business, patients

As healthcare administrators versed for decades in the intricacies of successful risk-based practices, we read this article with interest.  However, the author seemed to talk around the subject, ignoring the elephant in the room of risk-based payment.  Call it what you will – value-based, risk-based – the concept is the same: being paid to manage care. In our experience, it takes micro-management to be successful in risk, and that’s where the paths diverge.

The value-based paradigm is a toe-in-the-water good step in moving away from the fee-for-service mentality of lever-pulling payment (I do once, get paid once; I do 10 times, get paid 10 times) and its incentive to (perhaps) do more.  Value-based payment (VBP) asks us to focus on what the system is delivering to the patient, namely outcomes.  These models start with incentivizing providers to manage specific patient populations and medical conditions to achieve measures that have proven successful (in other words, promote patient health and well-being while lowering costs).  That’s the part this article doesn’t talk about though, and it’s the crux of risk-based payment.  The leap is huge from VBP to risk and readers of this article would do well to study the differences carefully before moving into any shared risk arrangements, which are presented as one step removed from the pay-for-performance of most VBP.

If your practice is financially sound, maximizing incentive payments for achieving quality measures, and you have a good handle on the data received and generated by your practice, the next step on the risk-model continuum might be worth exploring.  The road from study to implementation is long and practice structure is a big consideration.  Groups with many resources and one-stop-shop services naturally fare better than solo providers who refer all services to their hospital-partner.

Successful risk-based providers (meaning, lucrative practices with stable patients) have shifted their thinking to embrace managed care precepts, and know how to operationalize them in their businesses. Long-gone are the days when capitation and risk were believed to mean you skimp on care to keep more money.  It’s possible to practice honorable medicine, for the good of your patients, and still be profitable by working the system (network management, utilization review, health plan reporting and support, coding and quality) to your and your patients’ advantage.  But be mindful of articles that gloss over the attention and work involved.  They’re eerily reminiscent of the seemingly smooth road where Wile E. Coyote removed the sign reading, “Beware – Cliff ahead.”

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What We’re Reading – If you’re not prioritizing mental health, you are ‘missing the boat’

Many of our recent blogs have commented about how challenging this year has been, but it bears repeating.  COVID, social unrest, election stress and the trickle-down effects from all of these have ratcheted up our collective angst and threaten our mental health.  Our employees are also affected and HR gurus have been sounding the alarm:  Employers, take seriously workplace concern of mental health issues!

This recent article in HR Executive included a dialogue with the founder of a coaching organization that helps build employee resilience. He stated that absenteeism, presenteeism and burnout – all potentially devastating to employers, especially those bouncing back from closures and slow-downs – can go through the roof if we don’t take steps to mitigate the effects of stress.  Some interesting issues were highlighted:

  • Stress climbed 35% in the first six months of 2020, with extreme stress 18 times higher in women than men due to simultaneously balancing (or attempting to balance) remote work and their children’s remote learning.
  • Poor self-care. We’re not getting the sleep we need and have lived a good part of this year in fight-or-flight mode.  This spills over into all areas of our lives when we attempt to cope with stress by using band-aids like overeating, alcohol and couch-potato-ing.
  • Spiraling anxiety and lack of control. The metaphor of 2020 as a marathon and not a sprint is not really applicable because, as the interviewee pointed out, we don’t even know where the finish line is! For all the assurances of temporary measures, there doesn’t seem to be an end in sight, which only feeds the vicious cycle of fear and exhaustion.

What’s an employer to do?

We have to start off by recognizing that although we can’t fix all the issues, we can ratchet down the mental scream by just being human. Managers who engage in a lot of transparency and open communication can greatly impact their staff by showing empathy.  Honestly dialoguing about concerns and sharing vulnerabilities can go a long way in lessening some anxiety.  Brainstorming life/balance ideas with your employees can help them feel heard and valued and may yield unique solutions to their particular family issues. Maybe you can add some schedule flexibility that will help juggling moms and dads better meet their roles with less guilt and stress.  Sometimes a from-the-heart acknowledgement of the difficulties and gratitude for their efforts to get it all done are just the balm a beleaguered employee needs.

Finally, let’s not forget other tried and true HR tools, such as easy access to EAPs, mental health days, encouraging time off and other coaching-type resources.  Having that ready tool bag will help managers meet and defuse some anxiety, promoting well-being in their employees for the betterment of all.

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What We’re Reading – Why Dementia-Focused Home Health Provider Tender Rose Cherry-Picks Top Caregivers

Upon first glance of this article’s headline, you might think, as we did, that it’s a “puff piece” about a home care provider.  But the magnitude of the information – given COVID’s ravages of the home care industry this year – shifts our focus to what could be for 2021.

There is no doubt that dementia and Alzheimer’s disease are a constant challenge in delivering home care.  While some patients are physically healthy, their minds are being attacked by the sometimes-silent progression of dementia. The author stated that almost 80% of one home care provider’s patients have a primary or secondary diagnosis that includes some aspect of dementia. With the Alzheimer’s Association’s prediction of a tripling in people with Alzheimer’s by 2025, this specialized care will definitely be on the rise.

The key to better dementia home care is to provide person-centered, activity-based care, says the CEO of Tender Rose, a California-based company that has carved itself a niche in this crucial area of senior living.  The company goes beyond the traditional focus on activities of daily living (ADLs) or instrumental activities of daily living (IADLs) and seeks to meet its clients at their greatest non-physical need.  The CEO stated that they engage clients in activities “that bring them joy and meaning, at whatever level they can participate.”  This is especially important for those seniors who have no physical limitations, and is generally where traditional home care falls short.

Most caregiving staff has only the most basic dementia care training that doesn’t really focus on aspects of quality of life; the Tender Rose CEO explained that this approach is more likely to trigger agitation in patients which leads to behavioral issues.  Specialized dementia care education for staff, like that provided by a North Carolina dementia-focused training company, can help agencies break from the pack that sees dementia as a safety-only or ADL-only care model, and position them to dominate this growing and important segment of the home care market.

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Nurse Registry – not just Home Health Agency “Lite”

The nurse registry (NR) business model has evolved a great deal in CCG’s 20 years of business.  In our early days, the NR was a faster, cheaper-to-run alternative to the home health agency model, and still allowed for the provision of nursing services.  Those clients intended to run their businesses in much the same fashion as an agency, except the workers would all be independent contractors.  It was like the best of both worlds: a brand the owner could carefully craft and lower labor costs!

Over time, though, we’ve seen a “hands-off-edness” – if you will – in that the NR really resembles a broker.  Gone are the days where the owner could control all aspects of the provision of care (the what and the how), and super-impose its corporate identity on the business model.  NRs recruit the client, receive basic information about the client’s needs, explain the registry’s capabilities, and then assign a service provider to the client.

Instead of a linear relationship between the NR & the client and between the NR and the contractor, the relationship now resembles a triangle.  The NR performs specific functions (contracting, collecting payment, facilitating information, responding to regulators) and steps out of the performance aspect of the work; that is between the client and the caregiver. Consider the NR a matchmaker, of sorts, who gets invited to the wedding and the anniversary parties, but is not present at the dinner table every night between those milestone occasions.

Without a doubt, the NR model can be a lucrative and successful one, and yes, it is somewhat easier to establish and faster to launch, but a word to the wise:  if you’re a type-A personality who loves control, this model is not for you. Control is the most significant factor in determining whether an individual is an employee or independent contractor, and rest assured, the Department of Labor will assure the NR is not shoe-horning employees it controls and mis-classifying them as independent contractors. You will not be involved in the day-to-day aspect of the work but will still be responsible for making sure that the contracted services are provided and all parties are paid.

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There is Room for Home Care in Hospital-at-Home Programs

CMS recently announced “unprecedented flexibilities” in providing acute hospital care for patients in the home, but the concept of “hospital at home programs” isn’t new at all.  Johns Hopkins in Baltimore has operated such a program since 1994 and found it to be very effective:  it costs about 32% less than traditional hospital care, mean length of stay by one-third, lowers the risk of complications by 24% and has shown no difference in use of subsequent medical services or readmissions.  Moreover, in countries with single-payer systems – such as England, Canada, Israel and Australia – whose payment policies facilitate or at least don’t discourage it, this type of care has flourished. In Australia, for example, 60% of all patients with DVT were treated in the home in 2008 as were 25% of patients admitted for cellulitis.

A hospital at home system could produce dramatic savings for the US Medicare program and private payers, as shown by some pilots of the model which achieved savings of 30% and more per admission while delivering equivalent outcomes as traditional hospital care.  Accountable care organizations are also taking note of these statistics.

The Johns Hopkins program description has very specific parameters, honed from almost three decades of hospital at home care:

  • Narrowly defined criteria are employed to identify those patients whose needs may be met at home by visiting professionals. This type of care can best be implemented for conditions with defined treatment protocols, such as CHF, COPD, community-acquired pneumonia and cellulitis.
  • The suitability of the home must be assessed to ensure heat, air conditioning and running water.
  • Patients are outfitted with biometric and communication devices needed to oversee care, and the patient’s vital signs are monitored constantly and electronically.
  • An attending physician is assigned to the patient and this individual explains the treatment protocol to the patient, including the various clinical staff who will be providing needed care.
  • The physician visits the patient daily, or in some models, communicates with the patient via telemedicine equipment, and once the patient is stable and able to resume activities of daily living, he or she is handed off to the primary care provider. In one model, the hospital physician maintains oversight for at least 30 days to assure a seamless transition and avoid complications.

The Johns Hopkins model’s success is worthy of study (read more here), and program materials make it clear that an emergency or community physician makes the initial referral for hospital at home care after evaluating the patient’s needs.  This program isn’t suitable for everyone, but in specific cases, it can be beneficial and cost-effective. CMS’s recent expansion is geared at alleviating the burden of our nation’s hospitals as a result of another COVID wave.

One might be tempted to think this type of program will replace traditional home care; on the contrary, these are acute services that would usually require hospitalization.  We believe home care agencies can naturally complement hospital at home services after discharge, and so does Home Health Care News.  In 2019, an article discussed the synergy between acute care and home care for proper hand-off between the care “settings.”  In addition, given the healthcare system’s focus on social determinants of health and their impact on wellness, even non-skilled home care providers can play an important role in hospital at home programs.

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