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Teach office nurses about Medicare

An Alabama agency recently noticed a drop in referrals from physicians’ offices, which coincided with changes in how Medicare reimburses for home care services. The agency’s managers worried that some patients would fall through the cracks when physicians became too cautious to make referrals. Plus, nurses in physician offices sometimes called to ask what kind of referrals could be made under Medicare rules.

So Decatur (AL) General Home Health came up with an enterprising solution: lunch-time inservices for physician’s office staff. "Basic ally, we did some brainstorming on ways to get our faces and names in front of physicians’ offices," recalls Allyson Baker, RN, manager of clinical practice for the hospital-based agency, which serves four rural counties in northern Alabama.

Physicians were scared by the new Medicare guidelines, such as the rule eliminating venipuncture as a qualifying skilled nursing visit for home care, notes Pat Brooks, RN, education coordinator. "Physicians didn’t want to do anything wrong, so we thought we’d help them out with the new guidelines," she says. "We said, We’re here, and we still can take care of your patients.’"

The educational program focused on raising awareness for the entire home care industry in the area and not just at Decatur General Home Health, Brooks adds.

Baker and Brooks describe how the program works:

1. Survey physician’s office nurses.

Baker created a one-page survey that was mailed to more than 100 physician offices along with a self-addressed and stamped envelope. It included the physician’s name, address, and phone number, and it asked for the nurses’ names and whether they were RNs or LPNs. It also asked nurses which time of day would be best for an inservice and, if their lunch hour was the most convenient, what time they stopped for lunch.

The survey also provided space to write several educational topics that interested them. The last section listed courses the agency had developed in its continuing education program; the first two of those were on Medicare eligibility and criteria.

Some nurses chose to fax the surveys back, and the total return rate was more than 70%, Baker says.

2. Market the inservice.

The surveys indicated that nurses wanted to learn more about Medicare, and they wanted to attend a course on congestive heart failure (CHF), Brooks says. Also, most nurses said they wanted to attend an inservice during their lunch hour.

Decatur General set up the Medicare inservice in two separate, one-hour sessions. CHF was covered at a third inservice. The agency sent out about 100 fliers advertising the classes. The fliers asked nurses to call to register for the sessions, which were held at Decatur General Hospital in a lunch-and-lecture format. Participants were instructed to bring their own lunches.

The invitation wasn’t limited to physician office nurses. "Other agencies in the area, like durable medical equipment and infusion companies, were welcome also," Baker says.

The marketing efforts seemed to work. About 45 people showed up to each of the Medicare classes, and more than 20 people attended the lecture on CHF.

3. Teach nurses about Medicare reimbursement and other important topics.

First, instructors gave out plenty of handouts. "They loved the handouts," Brooks says. Then they showed transparencies to illustrate the lecture.

The first session covered Medicare’s and Social Security’s history. "I started out by telling them about how Social Security came about, using a time line," Brooks says. For instance, the Social Security Act was signed into law on Aug. 14, 1935. "We showed them the organizational and program changes that happened along the way and that Medicare wasn’t discussed until 1961," she says, adding that Lyndon Johnson signed the bill creating Medicare on July 30, 1965.

Brooks identified specific qualifying factors — physical, social, and environmental — relating to Medicare and home health services. She discussed the homebound status definition and how physicians need to follow up on patient care. Also, she explained that a skilled need must be present for home health to be involved.

"One of the problems we heard a lot was about the homebound status," Baker recalls. "They really didn’t know what that meant."

Brooks told participants what Medicare means by that term. "A homebound patient would be someone who cannot leave their home without a taxing effort, as identified in the Medicare manual," she says. "This means they only get out of the home to visit their doctors, and it exhausts them when they do."

Next, she covered the recent Medicare changes brought about by the Balanced Budget Act of 1997. "It used to be physicians could refer us patients for venipunctures, and we could see them once a month to draw blood work," she says. "But we can’t do that anymore because venipuncture no longer is a qualifying skilled service that allows the patient to receive home health services."

She explained to the nurses that a home health nurse still may provide venipuncture services to a Medicare patient, but there must be other qualifying factors, as well. For example, if the patient needs skilled catheter care or physical therapy, those would be qualifying factors. "But once the qualifying service is finished, they need to find another way to have their blood drawn," she adds.

If physicians are uncertain about whether a patient qualifies for skilled home care services, agencies such as Decatur General Home Health can evaluate the patient and make a recommendation. Decatur General provides this service at no charge, Brooks says.

"We see if there is anything we can do to help a patient," she says. "There might be teaching components that we need to address, or they may not be taking their medications correctly. You never know until you get out into the home."

The agency covered other Medicare details, as well, such as the Baltimore-based Health Care Financing Administration’s Operation Restore Trust, and what the industry is doing to police itself to prevent fraud and abuse.

The classes were well-received. Since then, some physicians are referring patients as often as they did before the Balanced Budget Act changes, Brooks says. Also, the nurses reported they learned a lot from the sessions.

"So many told us later they have had patients we could have seen, but they just didn’t know that," Baker says.


Allyson Baker, RN, Manager of Clinical Practice, Pat Brooks, RN, Education Coordinator, Decatur General Home Health, 1602 Church St. SE, Decatur, AL 35601-3402. Phone: (256) 350-4182. Fax: (256) 341-2646.