Thursday, February 17, 2011

Caregiving: When Does "Until Death Do Us Part" Take Effect?

As caregivers and patient advocates, we often face the issue of a patient who is so ill or incapacitated/suffering from Alzheimer's that physicians insist the patient no longer knows who his or her loved ones are.

Many of us have entered a hospital, hospice or bedroom only to be welcomed with a blank face and a confused "who are you"? We choke back tears and continue on in the role God expects of us - caregiver, friend, family member.

Often the role of spouse continues because of love and loyalty.  Often the role continues to ensure health insurance benefits.

Is there a time when the "healthy" spouse can morally and ethically "abandon" the technical role of spouse and begin a new relationship while the suffering spouse is still alive?

At what point do the marriage vows "until death do us part" take effect and the marriage end?  Obviously, divorce can end the marriage vows but the parties are very much alive.  What about a serious illness? Cancer?  Terminal illness?  Coma?  Alzheimer's?    

At what point can the healthy spouse be free to seek out and have a love affair with another person while still married to a terminally ill spouse? Is it okay so long as all conscious parties are fully informed? Or does having an extra-martial relationship while the spouse is incapacitated reflect a character flaw?

Moreover, what does it say about our society that we would institutionalize our ill and suffering with strangers (where abuse is rampant) so that we can continue with our lives?  We think we deserve something other than caring for those that suffer.  What precisely do we deserve that is more honorable than caring for the suffering among us?

When Doctors Gossiping About Patients Endangers Lives

HIPAA purports to protect patients.  But, as with any piece of legislation, attorneys are often hired to find ways to circumvent that protection.

Doctor A can certainly share confidential patient information with Doctor B to ensure continuity or furtherance of medical care.  Suppose Patient specifically and in writing states that he does not want current treater (Doctor A) to communicate/share medical information with prior treater (Doctor B).  An interesting ethical issue then presents itself when current treater (Doctor A) ignores Patient's directive and communicates with previous treater (Doctor B) in order to "coordinate care."

The ethical dilemma deepens when the conduct of both doctors continues without the knowledge or consent of Patient for over four months while Patient suffers from a life threatening condition.  

(1)  Neither Doctor A nor Doctor B intend to treat Patient

(2)  Neither Doctor A nor Doctor B assisted Patient in locating another qualified physician

(3)  Doctor A caused Patient to incur thousands of dollars in medical bills while at the same time never intending to treat Patient

(4)  Doctor A continued to communicate with Doctor B to "coordinate care" after Patient explained that Doctor B would not be retained to provide any care for Patient 

(5)  Patient spent four months waiting for Doctor A to make a decision about whether Patient was worthy of receiving medical care only to learn that Doctor A preferred Patient return to Doctor B 

Obtaining medical care used to be simple.  A person was sick, went to a physician, (presented an health insurance card) and received medical care.  In extreme circumstances, the health insurance card is not even necessary.  

Today's medical care is more complicated.  Some physicians are, frankly, unexplainable.  There is never, ever a reason to make a sick patient jump through hoops and perform parlor tricks to prove they are worthy of receiving medical care.

If the patient is sick then they should receive medical care.  We don't need Obama Care or The Affordable Care Act to accomplish that.  We need real, human, breathing, ethical physicians.  Those professionals are not as easy to find as one might expect.

Wednesday, February 9, 2011

Can You Trust Nursing Homes?

Gangrene and Osteomyelitis Cited in Wrongful Death Lawsuit Against Nursing Home   

The author of the above article and The Nursing Home Abuse Blog is Jonathan Rosenfeld.  He is an attorney.  But, more importantly, he is a solid person who is on the front line of protecting people in nursing homes.  His Blog is very instructive and should be required reading for caregivers.

We have talked about the topic of neglect and bedsores on this blog.  We have discussed how a horrifically neglected bedsore is a wound that (when ignored by medical personnel) can progress down to the bone and infect and kill that bone.  That is osteomyelitis. The infection can enter the bloodstream, the patient can become septic and die.  And that doesn't even begin to discuss the gangrene.

What are we allowing to happen to our vulnerable and elderly?

I understand the topic of nursing home care is very sensitive and personal.  The decision to place a loved one in a nursing home is not a decision that any family member or friend makes lightly or without thoughtful consideration.  That being said, nursing home placement is not an optimal living arrangement.  Hopefully, the placement can be as short as possible and a diligent family member or friend can be present as many hours as possible.

During one of my dad's first hospitalizations at Duke University Hospital, the hospitalist physician and nurses were anxious to have dad placed in a nursing home.  The attending hospitalist was so insensitive and told me "you have a life too."  

Dad was 4 months status post a completely successful colon cancer resection with very wide clean margins.  Dad was just suffering with a difficult urinary tract infection.  That was it. 

I asked dad's clinic urologist (also from Duke) whether dad should be in a nursing home.  I wanted whatever was best for dad.  

The urologist first reminded me that in elderly men often the only presenting symptom of a urinary tract infection is altered mental state (confusion).

The urologist (who knew dad better than the hospitalist) told me that if dad went to a nursing home:

  • The nursing home staff would be a catheter in dad (because it is easier for the staff);
  • Dad's urinary tract infection would continue until it ultimately reached his kidney and that would be the beginning of the end for him;
  • I would absolutely need to spend as much time in the nursing home monitoring dad's care as I did in the hospital because dad would receive less care/attention in the nursing home;
  • I would need to make sure dad moved every day so that he did not get bedsores or abused.

I chose to take care of my dad at home.  It wasn't easy.  But the alternative of risking a nursing home placement was not worth it.  

Sunday, February 6, 2011

Preventing Caregivers From Suffering Poor Health

Last week the Gallup Poll reported that Caregivers Suffer from Poorer Physical Health.  According to the article, 
Americans who work a full-time job and say they care for an elderly or disabled family member, relative, or friend, suffer from poorer physical health than those who work a full-time job but do not have additional care-giving responsibilities.
The implications from the medical community are obvious and the recommendations are equally obvious.  Maybe its part of the big plan of rationed care.  The Study certainly does not encourage families to care for one another.  rather, the Study suggests that it would be wise to: 

(1) get non relative home health care; or 

(2) get the elderly relative out of the house.

But in America, we take care of our own families whenever possible. We sacrifice for our loved ones to be together.  It's the American way.  That was my family.

So what causes the caregiver's health to fail?  

Why is care-giving so stressful?  

(1) Caregiver already sick or injured

Caregivers who are already sick or injured when the family member becomes seriously ill learn quickly to "suck it up" and do what needs to be done.  But the body can only withstand stand so much.

In my family, wheelchair transfers and physically helping my dad were exceptionally tough for me because (a) my left leg was in pain and (b) I was still undergoing cancer treatments.  

My weakened leg often caused me to fall down after I transferred dad safely.  Of course, I explained the problem with my leg to my Duke Orthopedic surgeon and explained how the hardware in my left leg hurt.  But my complaints were dismissed.

(2) Patient's documented symptoms ignored  by physicians

In order to provide the best care possible for their patients, physicians should work with the family caregivers.  

Caregivers are the ones that understand the patient's pain, appetite level, mood, urine and bowel output.  We take vitals 3-4 times a day.  We know what medication side-effects the patient experiences.

My dad was probably no different than other elderly patients that have complications from cancer chemotherapy.  My dad had bone injuries and terrible skin infections.  

Dad was in horrific pain and cried out in pain during the night.  Although I
requested dad's physicians address my dad's issues of pain, the physicians were concerned that my dad would get addicted.  The pain caused dad to lose multiple nights of sleep and consequently I lost sleep too.

At appointments, I told the nurses and physicians about dad's symptoms. When the nurses or physician asked my dad how he felt or whether he had a symptom that I described, my dad denied the symptom.  Dad would insist he was fine.  

Dad came from a generation and a family where men did not complain. Since my dad did not have dementia, the physicians chose to accept dad's word.  The doctors would ignore me, the caregiver.  That was wrong for the physicians to do.  

Dad's physicians should have had the sense to know that dad wanted to be a good patient, he did not want to complain.  The physicians should have listened to me, the caregiver.  The physicians should listen to every caregiver irrespective of whether the patient suffers from dementia.

Dad and I repeatedly left the physician's office.  We returned home and dad continued to suffer.  I continued to struggle to care for him without any cooperation from the physician.

The medical professionals must communicate, cooperate and work as team with the family caregivers.  In my dad's case, that did not happen.  Ironically dad's orthopedic surgeon was my orthopedic surgeon and knew that I was struggling to walk and move with my left leg.  As such, the orthopedic surgeon knew or reasonably should have known that his refusal to work with me as a team with respect to my dad's care would harm both dad and me.

Dad's health continued to deteriorate and so did mine.  But in my case, the deterioration of the caregiver's (me) health was avoidable.  Physicians saw dad and myself every week.  Physicians knew I was the caregiver and that I was injured and suffering.  

Even if the caregiver does not come to the "game" injured, the physician must respect the caregiver's work. If the physician does not respect the caregiver's work then, inevitably, the caregiver well-being and health will suffer.  In turn, the care to the patient will suffer.

What caregivers can do

I was actually injured (painful metal in my leg and completing cancer treatment) when I started care-giving.  

As a caregiver, you may be starting with a relatively healthy slate so to speak.  That does not mean that you are immune from wear and tear.  

(1)  Get a check up with a good physician that focuses on total well being.  This physician may not be your regular primary care physician (pcp).  

For example, at this point, I am both the patient and caregiver.  I am getting sicker with my bad leg and still have no physician to care for me.  I am proactive with my basic health as I wait for a surgeon to help me. I wish I had seen a caring doctor that focuses on the whole body when I was ignored by my regular pcp.

The physician I see now focuses on health, foods I eat, B-12 vitamin injections, compounded natural substances and reduces inflammation and weight.  He keeps track of my heart EKG and blood work.  I feel stronger and healthier now than I have in months - and that is with a painful, oozing leg.  I feel some control over my health.  

Caregivers would benefit from this type of medical intervention.  I had a psychiatrist and traditional physicians.  But the pain from the ignored orthopedic condition wore my body out.  I needed more than pharmaceuticals.

(2)  Caregivers must be insistent with the patient's physicians that there be a team approach to the care.  That team must include the caregiver.  

a.  Ask the physician what vitals or symptoms he wants you to track.  If the physician wants you to track pain, ask whether he wants you track on 1-10 scale.

b.  Get a notebook and be diligent about keeping track of the information. Be sure to include dates and times of information. 

c.  Before each appointment, write down a list of questions for the physician.

d.  Share the information and ask questions with the physician at each appointment.  

e.  Ask for the physician's input and plan based on the symptoms.  Use a different color ink to write the physician's plan.  If the physician chooses to do nothing regarding a symptom (eg. pain) then be sure and write that fact down.  Ask the physician why and write the reason down.  

f.  Take notes of what the physician says in addition to his decision regarding symptoms.
g.   Date the notes from the appointment. 

h.  Get copies of all blood work and test result.  Keep them all together by date.

The more organized you are as the caregiver, the less stressed you will be and the healthier you will be.

Friday, February 4, 2011

Top Ten Most Wanted for Health Care Fraud

As an advocate and caregiver, you must be on the watch for insurance, Medicare and healthcare fraud.  

Advocates and caregivers should examine and organize every medical bill, insurance statement and Medicare EOB.  

In my experience, the most common place where fraud is committed is in the area of Durable Medical Equipment (DME).  This includes everything from rented walkers and portable toilets (yes, you rent those things) to oxygen.

The most egregious example for me was a Request for Equipment that was contained the signature of a Duke University Medical physician and accompanying Medicare EOB indicating that Apria DME supplier was reimbursed by the US Federal Government for very expensive equipment that my dad never received.  

Although I reported the error, years later when my dad needed the equipment, the claim was disallowed because the fraudulent claim still appeared on the Medicare records.

The United States Department of Health and Human Services, Office of Inspector General is entrusted with the duty to prevent, investigate and prosecute Health Care Fraud.

As of the date of this posting, the current "Top Ten" are listed below.  
In all, the OIG is seeking more than 170 fugitives on charges related to health care fraud and abuse.

Carlos Benitez
Jose Benitez
Caridad Gullarte
Clara Gullarte
Leonard Nwafor
Luis Benitez
Dr. Steven Moos (captured)
Reynel Betancourt (captured)
Susan Bendigo
Eduardo Moreno

OIG Fugitives: “The Benitez Brothers”: Carlos Benitez, Luis Benitez, Jose Benitez

  • Carlos, Luis, and Jose Benitez, commonly referred to as the "Benitez Brothers," allegedly schemed to submit false and fraudulent claims to Medicare, pocketing approximately $110 million from Medicare, according to a Federal indictment.
  • The Benitez brothers owned and directed a string of medical clinics in the Miami area, purportedly providing infusion treatments to HIV-infected Medicare beneficiaries. But the medication the brothers provided to patients either was allegedly medically unnecessary or was never actually administered.
  • The brothers allegedly paid kickbacks to patients in exchange for the patients’ Medicare information, which they then used to submit false claims to the Federal Government for reimbursement.
  • More than 20 co-conspirators of the Benitez brothers have been charged in the Southern District of Florida with involvement in the HIV-infusion conspiracy. Most of them have pleaded guilty or have been convicted by a jury. A physician involved in the conspiracy was sentenced to a record-setting 30 years in prison.
OIG Fugitive: Dr. Steven Moos
  • Dr. Steven Moos is charged with drug possession, fraudulent Internet marketing, and child endangerment.
  • Formerly a general practice physician in Oregon, Moos lost his medical license after he repeatedly prescribed numerous prescription drugs over the Internet, despite warnings from the State medical authorities to stop such practices.
  • According to the Oregon Board of Medical Examiners, Moos prescribed drugs and refilled prescriptions without physically examining patients or obtaining health record information from them or their primary care providers.
  • After his medical license was revoked, Moos allegedly continued to practice medicine and prescribe drugs and made false statements on a Drug Enforcement Administration registration renewal application to conceal the fact that he no longer had a medical license to prescribe drugs, according to the indictment.
  • The Federal indictment stated that in the summer of 2002, Moos allegedly ordered misbranded drugs (including human growth hormone) from China. The drugs did not have adequate directions for use or warnings and other required information.
  • In February 2010, Moos was arrested and found guilty in the United Arab Emirates (UAE) of impersonating a physician and performing surgery in his villa. Sentenced to 2 months in prison, he also faces other charges in another part of UAE. U.S. authorities are working with UAE officials to bring Moos back for trial in the United States.

OIG Fugitives:Clara Guilarte, Caridad Guilarte, and Reynel Betancourt (CAPTURED)

  • Clara and Caridad Guilarte and Reynel Betancourt allegedly defrauded Medicare of nearly $4.3 million (and submitted $9.1 million in false and fraudulent claims), according to a Federal indictment. On November 30, 2010, authorities captured Betancourt in the Dominican Republic and subsequently sent him to the United States; the Guilarte sisters are still at large.
  • OIG is tracking down the Guilarte sisters in connection with the operation of the Dearborn Medical and Rehabilitation Center (DMRC) an infusion therapy clinic in Michigan. OIG alleges that the Guilarte sisters set up and operated the clinic where Betancourt was an employee.
  • All three fugitives allegedly committed health care fraud, conspiracy, and money laundering. The trio allegedly recruited and paid cash and other inducements to Medicare beneficiaries to visit DMRC and sign forms indicating that they received legitimate medical services, including injections and infusions of expensive medications, although the services allegedly were never provided.
  • All three are originally from Cuba: Clara Guilarte is a U.S. citizen, and both Caridad Guilarte and Betancourt are permanent U.S. residents.
OIG Fugitive: Susan Bendigo
  • Along with her co-conspirators, Susan Bendigo, who was born in the Philippines, is accused in a Federal indictment of billing Medi‑Cal, California's Medicaid program, for $17.1 million, collecting $10 million, about half of which came from the claims she submitted for services she provided with unlicensed staff.
  • A registered nurse, Bendigo was director of nursing for a company that provided nurses for home health agencies. Investigators say that from May 2004 through May 2007, she sent unlicensed nurses to treat patients under Medi‑Cal, even though she knew that Medi‑Cal required licensed nurses to perform the work.
OIG Fugitive: Leonard Nwafor
  • Through his durable medical equipment (DME) company, Pacific City Medical Equipment, Nwafor and his co-conspirators billed Medicare for $1.1 million and collected $525,000 in fraudulent claims for equipment such as motorized wheelchairs, scooters, and hospital beds for beneficiaries, according to a Federal indictment.
  • Based in the Los Angeles area, Nwafor used physicians’ Unique Provider Identification Numbers to bill Medicare for the equipment, even though those doctors did not examine Nwafor’s clients.
  • OIG investigated Nwafor
  • In the fall of 2008, a jury convicted Nwafor of conspiracy and health care fraud. He was to be sentenced in January 2009, but failed to show up in court. In March 2010, he was sentenced in absentia to 9 years in Federal prison and ordered to pay back more than $525,000 to Medicare.
OIG Fugitive: Eduardo Moreno
  • According to an April 2007 Federal indictment, Eduardo Moreno allegedly stole hundreds of thousands of dollars from the Medicare program, submitting false and fraudulent claims for durable medical equipment (DME) “and related health care benefits, items and services” that were medically unnecessary.
  • Moreno used a “straw owner” and other methods to hide the money and property he obtained through these fraudulent schemes, the indictment alleged. (A straw owner is an individual who maintains the appearance of owning property in order to disguise the identity of the real owner.)
  • He was arrested by the Miami Police Department on an open warrant. He failed to appear in court and his current whereabouts are unknown.
Be proactive - watch out for your own elderly and those for whom you care.  In addition, I recommend that you watch out for your neighbors.  I have known my elderly next door neighbors since I was 4 years old.  

Today both husband and wife are disabled (stroke victim and Alzheimer's) and are living in their own home.  Periodically, I make contact with their home health workers and re-introduce myself, ask if there is anything I can do and thank the ladies for their kindness.  

I am keenly aware that there are beautiful, kind people in this world.  However, I am not so naive to think that, in these desperate times,  the elderly and disabled cannot be victimized. Neighbors and friends must not presume the elderly are safe simply because a home health worker drops by everyday.

Advocates Must Stop Hospital Staff From Abusing Elderly

As an advocate/care-giver/adult daughter of a dad, I watched many events take place in hospitals, clinics, Emergency Departments (Duke University in Durham and Raleigh North Carolina)

As with all hospital stays, some procedures and events were positive and some were negative.  But sometimes, I actually needed to intervene because hospital and medical staff were abusive to my dad.  This is precisely why family members cannot just leave the elderly at the hospital and expect total strangers (albeit medical care professionals) to have your loved ones best interests at heart.

As a care-giver and advocate, you may find yourself in the position of witnessing abuse on your loved one.  There isn't time to make a phone call or have a discussion.  You must just intervene and speak up immediately.

Below are two of my personal examples:


My dad was in the hospital and the physician ordered a foley catheter.  Two very young nursing assistants (20 somethings) were assigned with the task.  I left the room to give dad some privacy.  But I did not go too far.

As I leaned outside the door, I heard the two young ladies alternating between giggling and yelling at my dad to remain still while they were jamming a cath up his penis.  

And then a heard a slap sound.  And then I heard my dad's frightened, quivering voice begging "don't hit me."

My response - I immediately opened the door and told the ladies to stop whatever they were doing.  Before I get further than "stop that is enough," one of the ladies yelled out "we need restraints."  

I told the nurses "no restraints, no catheter."  As they left the room, one nurse informed me "the cath is already in."

I looked at my dad and he was shaking and in tears. I held dad in my arms until he stopped shaking.  

I was in shock at the nurses' behavior and could not immediately process why the nurses would have be requesting restraints ... unless they wanted to punish my dad for some unknown reason.

If you ever hear a nurse yelling (much less hitting) your loved one or if you hear your loved one frightened then you must intervene and stop the behavior.


I was in the hospital with my dad when he was post operative and in need of 24 hour observation.  I was the "observer" as many hours as possible.  But for the few hours that I drove to my mom's home and helped her out with meals and caring for the animals, the hospital placed on of their employees.

One evening, I arrived back to spend the night in dad's hospital room.  When I arrived in dad's room, I was horrified to see that the hospital employee (called a "sitter") had turned all the lights on and was chatting with a friend on her cell phone.  She had the television on loudly.  There was zero consideration for my dad.

I said "hello" to my dad and smiled at me.  Then I turned down the television.  I politely told the "sitter" that she could leave now.  She said that she was told to stay with him all night.  I told her that was unnecessary.  

My dad thanked her for keeping him company.  Then, the "sitter" asked my dad (with almost an evil grin on her face) "do you remember me"?  My dad said "sure."  Then, the "sitter" asked (as if to taunt my dad)  "okay, then what's my name"?  Before I could answer for my dad, there was a knock on the door and another hospital employee entered my dad's hospital room to deliver the "sitter" the Dominos Pizza she ordered for herself.

My response - I excused myself from the room and went to the nurses desk.  I asked to speak with the charge nurse.  I explained to the charge nurse what had transpired and then stated that I did not want that "sitter" in the room with my dad ever again. Period.  

There are many more examples of times when I intervened at Duke University Medical (both in Durham and Raleigh) to protect my dad.  I will share more later.

All advocates and care-givers should protect the elderly from abuse - even if the abusers are medical care providers.

Wednesday, February 2, 2011

Federal Government Wants to Tighten Hospice Admissions. Why?

The Affordable Care Act of 2010 (ACA),  Pub. L. 111-148, enacted March 23, 2010 (aka Obama Care) includes a section that applies to the terminally ill.

The problem from the perspective of the federal government is that the terminally ill in hospice care are living beyond the expected 6 month period.

Instead of analyzing what aspects of the hospice care experience are extending the lives of terminally ill patients, our federal government (in its infinite wisdom) chooses to create yet another burden for the medical practitioner.

Face-to-face requirements in several care settings have been established through the Affordable Care Act (ACA).  The actual face to face requirement is designed to reduce fraud, waste, and abuse by assuring that physicians and other medical care providers have met with the terminally ill to ascertain their specific health care needs.  

I understand that fraud exists in the Medicare system.  But it is absolutely insulting to suggest that a physician would falsify a hospice certification.  It is more likely that the terminally ill patient is receiving less aggressive care in hospice care.  Perhaps the less aggressive care has brought peace to the patient.

Medical care providers are reasonably concerned that the rules may in fact delay care for the patient.  Patient advocates must maintain communication with the medical provider's office in order to assure timely access to necessary services. 

When the hospice face-to-face requirements become effective, a hospice physician or hospice nurse practitioner must:
have a face-to-face encounter with each hospice patient, whose total stay across all hospices is anticipated to reach the 3rd benefit period, no more than 30 calendar days prior to the 3rd benefit period recertification, and must have a face-to-face encounter with that patient no more than 30 calendar days prior to every recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care.[42 C.F.R. §418.22(a)(4)]
The required narrative of certification must include a statement, written directly above the physician's signature, attesting that the physician confirms that the narrative is based on his or her examination of the patient.[14]  In addition, the narrative for the 3rd benefit period and each subsequent benefit period must explain why the clinical findings of the face-to-face encounter support a life expectancy of 6 months or less.[42 C.F.R.42 C.F.R. §418.22(b)(3)(iii)]
The certification of the physician or nurse practitioner who performs the face-to-face encounter must contain a written attestation that he or she had the face-to-face encounter with the patient.[42 C.F.R. 42 C.F.R. §418.22(b)(3)(v)]  The certification must be in writing; and must be a separate and distinct section or an addendum to the recertification form; and must be clearly titled.  If done by a nurse practitioner, the nurse practitioner must state that his or her clinical findings from the face-to-face encounter were provided to the certifying physician. [42 C.F.R. 42 C.F.R. §418.22(b)(4)]  Moreover, all certifications and recertifications must be signed and dated by the physician(s), including the benefit periods to which the certification or recertification applies.[42 C.F.R. 42 C.F.R. §418.22(b)(5)]

At this point, the face to face meeting requirements have been postponed. 

Sent: Thu Dec 23 13:46:42 2010 
Subject: Hill Notification: Additional Time to Establish Protocols for Newly Required Face-to-Face Encounters for Home Health Certification and Hospice Recertification
U.S. House and Senate Notification December 23, 2010
To: Congressional Health Staff
From: Amy Hall Director, Office of Legislation Centers for Medicare & Medicaid Services
Re: Additional Time to Establish Protocols for Newly Required Face‐to‐Face Encounters for Home Health Certification and Hospice Recertification
Due to concerns that some providers may need additional time to establish operational protocols necessary to comply with face‐to‐face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient’s eligibility for Medicare home health services and of recertification for Medicare hospice services, the Centers for Medicare & Medicaid Services (CMS) will expect full compliance with the requirements, beginning with the second quarter of CY2011.
Section 6407 of the ACA established a face‐to‐face encounter requirement for certification of eligibility for Medicare home health services, by requiring the certifying physician to document that he or she, or a non‐ physician practitioner working with the physician, has seen the patient. The encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. Documentation of such an encounter must be present on certifications for patients with starts of care on or after January 1, 2011.
Similarly, section 3131(b) of the ACA requires a hospice physician or nurse practitioner to have a face‐to‐ face encounter with a hospice patient prior to the patient’s 180th‐day recertification, and each subsequent recertification. The encounter must occur no more than 30 calendar days prior to the start of the hospice patient’s third benefit period. The provision applies to recertifications on and after January 1, 2011.
Although many hospices, home health agencies and physicians are aware of and are able to comply with this policy, CMS is concerned that some may need additional time to establish operational protocols necessary to comply with this new law. As such, CMS expects that during the first quarter of CY 2011, home health agencies and physicians who order home health services will collaborate and establish internal processes to ensure compliance. Likewise, CMS also expects hospices to establish internal processes during the first quarter. Beginning with the second quarter, CMS will expect home health agencies and hospices to have fully established such internal processes and have appropriate documentation of required encounters.
CMS will continue to address industry questions concerning the new requirements, and will update information on our Web site at and CMS and its contractors will also use other communication channels to ensure that the provider community is properly informed of this delay.
If you have any questions about this announcement, please contact the CMS Office of Legislation.
42 C.F.R. §418.22(a)(4)

Caregivers should read about hospice programs and try to implement aspects of hospice care in the home environment.

Regardless of the the seriousness of your patient's illness (simple cold, broken leg or cancer), strive to create an environment of peace, flexibility and compassion. 

J Indian Med Assoc. 2001 Dec;99(12):687-8, 690-1, 709.
The concept of hospice in theory and practice.

Center for Medicare Advocacy

Drama Exists as Duke University Medical Wall of Silence Persists

Congratulations to "Duke Fact Checker" for being the conscience at Duke University.  The work done on this site is commendable and a service to the scientific community and the public at large.

Silence may be golden.  But when the silence relates to innumerable cancer patients who trusted Duke Medical physicians and researchers with their lives, the silence is inexcusable.

A recent piece of excellent reporting:

Monday, January 31, 2011
While Brodhead read Milton poems, Duke got smothered by Potti Mess in January
Search terms: Duke University Anil Potti 
Note: In preparation of this report on the Potti Mess and a coming special report on the campus-wide leadership of President Brodhead, FC asked VP for PR Michael Schoenfeld for input, for information and suggestions. He has ignored our request.
✔✔ In January, the Potti Mess spun out of control, pushing Duke deeper and deeper into a quagmire. FC shall detail what happened in a moment. 
First, we want to address the leadership that President Brodhead has provided during this crisis, now eight months old. 
We find only two statements by Brodhead, both made during routine start-of-the-academic-year conversations with the editorial boards of the Herald-Sun and News and Observer. 
Neither comment was significant enough to be reported in the Chronicle. 
Immediately after The Cancer Letter revealed Potti's fake claim of a Rhodes Scholarship and the Rhodes Trust confirmed there was no award, with other credential issues looming, Brodhead cautioned editors and reporters not to reach rapid conclusions of truth or lie, for there could also be "intermediate explanation."
And in another editorial board meeting, Brodhead was asked how in hell Potti ever got a job on our faculty: 
Brodhead: "The university will in general continue to accept credentials on their face as presented by the people who present them... We're not going to start running background checks and police checks on everybody... You can't reasonably do that, nor is there a need to."
Dare we point out that the President was immediately contradicted by Schoenfeld:
“In terms of faculty, [hiring] is a very thorough and rigorous process and involves extensive checking of references, conversations with people who worked with faculty members and reviewing work they do.” 
✔ This is not leadership; the request to wait for an "intermediate explanation" is mush from an English professor, not the mighty declaration of principle we needed from the guy in charge, that anyone falsifying credentials would be thrown out on their ass. And the waffling on how Duke vets its employees is bewildering.
✔✔ Loyal Readers know of our repeated concern for Potti's patients. We believe there were far more than generally reported: the total of 107, 108 or 110 represents only those enrolled when Duke finally pulled the plug on his "clinical trials," which is to say experiments on human beings. We believe -- but have been unable to confirm -- that over time more than 300 people participated in these experiments, with perhaps as many as 1500 undergoing invasive tests to see if they qualified. 
Has Brodhead ever said a word to any of these people? People who came to Duke in desperation, who got a quack instead of help and care.
Wouldn't it be appropriate for our President to address these people, to express our remorse, to reassure them, to bring them together for group therapy to help them cope with their mental anguish, to pledge that Duke will help them now obtain the best cancer care possible?
These people got ignored. They got silence from our President. 
And needless to say, in a rosy Happy New Year sent belatedly to all alumni on January 21, Uncle Dick did not mention the Potti crisis at all.
Pathetic. Dick, just pathetic. 
✔✔ And now the horrible month of January, with the Potti Mess spinning out of control: 
✔ 1) As the Chronicle reports today, a third research paper that Potti published with his mentor Dr. Joseph Nevins has been retracted, which is a nice way to say withdrawn in disgrace. More to come. 
✔ 2) In January, Nevins, Barbara Levine University Professor of Breast Cancer Genomics, saw the research center he headed disappear from the face of this campus. That is, the Center for Applied Genomics and Technology where Potti worked. 
We have been cautioned against reading too much into this -- for two other centers that neither Potti nor Nevins were involved in were also terminated as part of a review of the entire genome enterprise prior to its 10th year. The Cancer Letter, which has broken most of the Potti stories, does not agree with that interpretation. 
✔ 3) As the Institutes of Medicine (IOM), which is supposed to conduct a well financed "unfettered" investigation of the Potti Mess arrived on campus to begin its work, The Cancer Letter gave us a peek at some of the documents the IOM has amassed. 
BOMBSHELL: The National Cancer Institute, which was using federal money to pay for some of Potti's research, became so concerned that on June 29, it summoned top Duke officials to its offices in Maryland for a showdown. For purposes of our analysis, the key person there was Sally Kornbluth, PhD, professor of pharmacology and cancer biology, and vice dean of the medical school. 
This would not have been the first time that a highly authoritative challenge to Potti's work landed in her lap: Loyal Readers will recall how the previous November, as Duke's first internal investigation into Potti was beginning, she and Dr. Michael Cuffe, another vice dean, received an extraordinary letter from the eminent MD Anderson Comprehensive Cancer Center in Houston, with Dr. Keith Baggerly outlining in new detail precisely what was phony about Potti's research. 
This letter was concealed from the investigation. Concealed. Repeat, not sent to the investigators, concealed. 
We are told by a reliable source that Kornbluth and Cuffe were only some of the people in this decision; one account says "leadership": of Duke signed off -- in writing -- on this course. FC is at work trying to pin this down. (Later, Cuffe told Nature that if a similar situation were to ever occur again, he would forward “every shred” of evidence to the review panel. Whew.)
And even after the internal Duke investigators gave rousing approval to Potti's work, the letter was not send along as part of a reconsideration.
Rather, Kornbluth and Cuffeh and Cuffe signed off on the investigation -- allowing clinical trials to continue. 
Thus, Kornbluth was in a unique position to know the full dimensions of the implosion. But she -- and others -- did nothing. Only in the past horrible month, these details fell together. 
✔4) It appeared more and more that the Institute of Medicine isn't delving into the nooks and crannies of Potti at all, but rather is more interested in a broad survey of standards in the emerging field of genome studies. This is undoubtedly important -- but not at the expense of a thorough investigation into Potti. 
✔ 5) BOMBSHELL We learned that the Food and Drug Administration is on Duke's tail too. Part of Potti's clinical trials fell under their jurisdiction, because the tests that he used to determine who might benefit from what cancer drug are considered a "device." 
No one can plead ignorance. On other similar trials, Duke doctors, including Nevins, secured FDA approval. Yet in documents just revealed, Duke’s Institutional Review Board put N/A for non-applicable next to checkboxes intended to indicate whether this form of FDA clearance had been obtained.
Investigators are on campus. 
✔6) BOMBSHELL During the month of January, we learned that some of the people in Potti's clinical trials for lung cancer, received a chemotherapy cocktail that he concocted -- that is -- a combination of very powerful drugs used in a way not approved by drug regulators.
This should be a criminal offense. 
✔ 7) Also in January, Duke surrendered the last of the Potti research funds, multi-year grants from the federal government involving cancer research, one with one year and $200,000 left, and the other with six months and $100,000. Potti's lab -- once vibrant with hope of a major scientific breakthru -- had shrunk to four employees, and they learned they are being laid off. 
✔ 8) As FC reported, Potti started to emerge from the seclusion of his Chapel Hill home... building his Facebook site, sending out tweets ( and worse, apparently trying to capitalize on his years at Duke, presenting himself as a cancer doc extraordinaire, misleading with a regurgitation of a seven year old press release announcing a humanitarian award. So far as we can find out, Duke has filed no report on Potti with the North Carolina Medical Board.
✔ 9) A Raleigh law firm that has taken on Duke University in the past says it is doing "research" on the Potti Mess. The firm Henson Fuerst has now sent out several press releases seeking information from Potti patients, which seems to FC like a thinly disguised effort to sign them up for lawsuits. 
✔✔ What will February hold? Brace yourself, fellow Dukies. At Bingham Young University, Baggerly (the whistle blower from MD Anderson Comprehensive Care Center) reviewed the Duke mess for the fourth joint international meeting of the IMS (Institute of Mathematical Statistics) and ISBA (International Society for Bayesian Analysis). 
They deal with highly technical stuff, but everyone will be able to understand this prediction: 
"Hold on folks, the ride’s just beginning." 
Thank you for reading Fact Checker.