Thursday, December 30, 2010

Out of tragedy...

This past summer, I wrote about a tragedy that took place when a local family vacationed on Martha's Vineyard... and our Hospice's efforts to help with the healing and grieving process.  See here.

We recently received a nice letter from the Executive Director of Hospice of Martha's Vineyard which spoke of the efforts of our own David Quemere.

Here's a copy of that letter... with a big thank you to David and our exceptionally compassionate caregivers at VNA Hospice Care.

Hint: If you click on the letter, you'll be able to read it in a separate (and bigger) window - depending on which browser you're using.

Planning End Game

I believe it's how we're hardwired, how we approach life.  Some of us love to live in the moment and some of us love to plan.  Some of us experience a thrill in not knowing what's around the next bend, others of us feel anxiety when the road ahead is unclear, uncertain. 

Some of us focus on only the very next chess move.  And some of us plan two or three moves ahead.

Don Schumacher, head of the National Hospice and Palliative Care Organization (NHPCO), has some common sense advice about planning two or three moves ahead...
December 28, 2011

NHPCO President and CEO Don Schumacher has an opinion article posted on that we want to share with members. The article can be found on the CNN website and is copied below.

Why end-of-life planning is smart, necessary.

By J. Donald Schumacher, Special to CNN

(CNN) -- Thinking about death can be frightening, no matter your age or medical condition. As we get older, the reality of our own mortality tends to come into clearer focus; this doesn't make talking about death or life-sustaining treatments any less frightening though.

It was fear -- stoked by certain politicians -- that led to the inaccurate and misguided "death panel" rumors that surrounded health care reform proposals last year.

Beginning January 1, Medicare will reimburse physicians who advise patients, in voluntary discussions, about their preferences for end-of-life care treatment during their annual Medicare "wellness visit." This is advance care planning, and it is a good thing for seniors, their families and health care professionals.

It's not new. In 2008, President George W. Bush signed legislation that allowed end-of-life planning to be part of a patient's "welcome to Medicare" exam. Health care reform turned the welcome visit into an annual wellness visit. And now regulations clarify that these important discussions will be covered should the Medicare beneficiary wish to take advantage of this opportunity.

Advance care planning allows a person to make his or her wishes and care preferences known before being faced with a medical crisis. Advance care planning is simply smart life-planning.

Another way to think about advance care planning is that it's like planning a trip to an unfamiliar destination. If you're like many people, once you have your destination in mind, you begin mapping the route you will take to get there. Some people consult AAA or Google Maps to help them chart their course. Other people talk to friends and family members about their experiences on their trips.

While people approach mapping their route in differing ways, few would expect to arrive at their destination safely and comfortably without having a well-thought out map in hand before hitting the road. Yet only 30% of Americans have a living will, a map detailing where they want their health care to go should they become unable to voice their wishes.

An individual's personal wishes, beliefs and values are among the most important factors when making care decisions brought about by a serious or life-limiting illness. Such wishes and preferences can be known only if they are discussed openly.

Research has shown that patient-physician discussions result in a higher quality of life for patients and their family caregivers facing the end of a life.

By having Medicare cover these voluntary consultations, beneficiaries will be able to get information that will help them make their own decisions about their care and what they would or would not want at life's end. And it's only appropriate that patients should be able to have these discussions with the very physicians who have been caring for them and that these doctors be compensated for this valuable service.

An advance care planning consultation is not about limiting or rationing care. It's not about hastening death. It's not about having choices made for the patient. It's not about saving money.

Advance care planning is about examining options, planning and communicating the choices that the individual wants -- either to limit treatments, accept all treatments or something in between. The course charted is decided by individual patients, not their doctors, and certainly not the government.

Advance care planning includes completing a living will and appointing a health care proxy.
  • A living will charts the course for your health care, letting your family and health care providers know what procedures and treatments you would want provided to you and under what conditions.
  • A health care proxy or health care power of attorney form allows you to choose someone you trust to take charge of your health care decisions in case you are unable to make those decisions yourself.
  • Advance directives, as these documents are also known, can be changed as an individual's situation or wishes change.
Based on my 35 years of experience running hospice programs and caring for people at life's end, I know firsthand that frank, open discussions with one's health care providers can relieve anxiety about a situation that we all will one day face.

It makes sense that Medicare help facilitate this important planning.

The opinions expressed in this commentary are solely those of J. Donald Schumacher.

Tuesday, December 28, 2010


If you've been following this blog, you know that the Centers for Medicare and Medicaid Services (CMS) have imposed significant new physician face-to-face documentation requirements along with the dramatic funding cuts... all set to hit on January 1st.

Well, there's some good news to report:

Thanks to the advocacy of our Federal delegation and support from our partner physicians including Board members Drs. Bob Witzburg and Juergen Bludau, last week, CMS announced that they will provide a three month transition period for enforcement of the face-to-face encounter requirements.

I want to emphasize that CMS is requiring, and VNAB will meet, the January 1, 2011 implementation date of the face-to-face encounter rule. The difference is that now we have three months to iron out the kinks in the system and to work with our physician partners to ensure that patients do not lose access to home health care services while we proceed with implementation of the rule.

Our VNAB team has done a fantastic job getting our systems and processes ready for implementation of this rule so I am confident we will move forward internally with minimal disruption on January 1.

Innovation, the key...

Though the year had a few bumpy spots (for example, "antenna-gate"), I'm wondering if any company in the history of commerce has had a better year than Apple did in 2010.  Here's a "fanboy summary" (I didn't coin that) that's floating around the internet. 

Makes you think about the role of innovation and exceeding customer expectations again and again and again...

The Post Office has nothing on us...

From an email to all employees:
"That's what team work is all about..."

So says our own Dan Pagliuca when I thanked him for driving a clinician to a home in the North End during yesterday’s snowy weather.

Because last winter was so uncharacteristically mild, I never had a chance to see firsthand one of the facets of VNAB & Affiliates’ reputation - that inclement weather doesn’t deter the staff and managers from rising to the occasion and providing care to those who most need it. Well, that changed yesterday… and I was able to witness why our organization has deservedly earned that reputation.

This email is a big thank you to everyone who successfully contended with the challenges of the recent blizzard. Over the past 24 hours, I’ve heard numerous stories of commitment and persistence for which I’m grateful. Some of those stories relate to night and weekend staff and managers working hard to make sure that “must see” patients were seen, team members withstanding rough commutes to get to the office, clinicians navigating parking bans and employees volunteering to transport our staff members to patients’ homes.

Again, thank you to all who contributed.


Sunday, December 19, 2010

Would you hike this trail?

"This walkway now serves as an aproach to Makinodromo, the famous climbing sector of El Chorro in Spain's Andalucia. And it is the hairiest path. The area of El Chorro situated in the south of Spain is renowned amongst travelers and mountain hikers for its stunning scenery and climbs, yet this is not the main attraction on offer, El Chorro is host to one of the most dangerous walkways in the world, built by workers to transport materials between the Chorro and Gaitanejo Falls."  Source here.

Had it all happened in 2010

Regardless of your religious bent, you have to admit that this is clever.

Friday, December 17, 2010

Thursday, December 16, 2010

An unbalanced delay tactic?

Health reform unconstitutional?  So says a Federal judge in Virginia.  The center of this brewing storm relates to the ability of the U.S. Government to mandate that individuals purchase health insurance coverage.

And today, attorneys from 20 states have petitioned to have the new law overturned on the grounds that it will expand the government's powers in dangerous and far reaching ways.

I'm contrasting these actions with the comments of both Democratic and Republican Congressional staffers during our visit to Washington DC a few months ago (pre-midterm elections).  The prevailing sentiment was that no matter the outcome of the elections, there would never be enough political vim and vigor to overturn the reform law.

But the issue they did not address was whether or not there might be enough legal basis to attempt to accomplish the same task.  The legal challenge has been brewing for a while, but the recent decision in Virginia and the persistence of the 20 anti-reform states lends credence to the argument that legal action (or inaction) could tie up implementation of the major provisions of the law so as to render it largely irrelevant.  I've asked a few attorney friends to comment on whether there is enough legal standing to truly impact reform law implementation.  The emerging consensus view seems to be that the legal challenges may not have a great likelihood of holding water... yet, they may force substantial delays and postponements of key milestones such that a future Congress (which could actually have the votes to reverse major reform provisions) could take up the issue.

This is reminiscent of the onetime Massachusetts health reform deal crafted during the Dukakis Administration but then carved thin by the effects of time and ensuing economic crises which pushed it so far toward the back burner that it fell off the stove.

The home health industry does not have the luxury of waiting to see how these legal and political theatrics resolve.  Massive Medicare reimbursement cuts are upon us now.  Draconian face-to-face and documentation requirements are due to hit next month which will likely have the unintended effect of reducing access to services for the most needy among the populations we serve.  I fear that the high impact provisions on home care will hit now while many of the downstream provisions will ultimately be delayed or even dropped.

If we're going to have these delay tactics, it would be best if their impact could be fairly distributed...

Farewell, friend of hospice movement...

This from Carol of our VNA Hospice Care:
Elizabeth Edwards, long an advocate of hospice care, died on December 7. Her lengthy illness and death received extensive media coverage, and much of it referenced her passionate support for hospice. For that support, Edwards was named NHPCO’s 2009 Person of the Year.

Edwards spoke at the 2008 NHPCO Clinical Team Conference several years after her diagnosis with breast cancer. On that occasion, Edwards said, “Throughout my life, both personally and professionally, I have had the opportunity to see how people have been affected by illness and loss and the role the healthcare system may have played as they dealt with change in their lives. I also know that people can find a great deal of hope, even in the most challenging of life’s situations. Hospice and palliative care professionals support and care for people at a time when hope can be hard to find. The professionals of NHPCO know more than I will ever know about providing that care; I know more than I wish I knew about receiving it, and I am happy to share my perspective with them.”

Edwards, who at 61 still had two young children at home, continued her treatments until her physicians suggested it was time to stop. MarketWatch blogger Kristen Gerencher wrote of her, “Recent research suggests that starting palliative care early — at the time of diagnosis — can actually prolong life and not just increase its quality. That doesn’t mean you have to give up on aggressive treatments, and it sounds like Elizabeth Edwards went that route as long as she could and as long as that made sense to her. Maybe her life and death will usher in a new era of frank talk about what end-of-life care can be when people have grown-up conversations about the trade-offs of various approaches.”

Politics Daily’s Eleanor Clift, herself an ardent champion of hospice since her husband’s illness and death, said, “Their time in hospice, brief as it was, allowed the Edwards family – Elizabeth and John, and their grown daughter Cate – to re-visit old wounds along with the new ones that ended their marriage. Seeing a loved one on his or her death bed tends to focus the mind, and for Elizabeth, who was courageous and clear-eyed all along about the progress of her disease, hospice gave her and her estranged husband a chance to heal those wounds, forgive each other, and sort out what they want for their children, Emma Claire and Jack, who are very young.” (Politics Daily)

Holiday fun at our Southwest Office party... more fun coming today!

25+ Years of Service!  Congratulations Sue, Katy and Annette.

Saturday, December 11, 2010

A story about talent, a Mac and the power of Youtube...

According to my brother, Rob, film professor at Case Western University:

this guy shot the location footage for this film in a week
then spent three years on his mac
within a week after posting this on youtube, he was in hollywood fielding offers. he directed the film 'monsters,' out now

Thursday, December 9, 2010

Myths Surrounding Hospice

From VNA Hospice Care:

Due to the mystery of death and our inherent fears of the unknown, the word “hospice” has taken on negative and to some, perhaps, frightening connotations.

Myth: “Hospice hastens death”

Hospice does not hasten death nor does not it condone, participate or philosophically agree with the practices of euthanasia or physician-assisted suicide.

Hospice is the antithesis of such practices. Hospice care is about living your best quality of life until you die naturally.

Several recent studies have been done that show people who access hospice care earlier in their disease processes live longer and better lives than those who did not.

Myth: “Hospice withholds treatment”

The type of the care that someone receives while still hoping for cure changes as cure becomes less likely. People mistake this change in care as a lessening or a “withholding” of what is often called “aggressive” treatment. Hospice is just as “aggressive” about the care that is provided as any other form of health care.

Patients on hospice routinely still receive chemotherapy, radiation, dialysis, blood transfusions, intravenous or enteric nutrition, physical/occupation/speech therapies and diagnostic work-ups, for as long as this care is medically appropriate and indicated.

Myth: “Hospice is only for the hopeless”

The nature of hope changes throughout our lives. When we are young we hope for success, happiness and many other things for ourselves and for those we love.

When we become sick, we hope for cure and when cure is no longer possible, we hope our remaining days are ones of comfort, dignity and ones in which we are surrounded by those we love.

Hospice care is about hope.

Question of the Month:

My patients always worry that if they go onto hospice services and have to sign a “DNR” they will no longer be able to access the hospital and will loose their doctor.

What should I tell them?


Patients do not need to agree to be “DNR”. This is a choice they make and does not affect their ability to access hospice care or the hospice benefit in full. They can continue using the same hospital for any of their care needs, as necessary, and they will keep the same doctor they have come to know and love. Nothing changes.

Want to learn more?  Click here.

Wednesday, December 8, 2010


Press Release:
Boston, MA - On Sunday, December 5th the VNA of Boston’s 17th Annual Holiday Express Train Ride chugged along the Haverhill/Reading Commuter Rail line filled with nearly 2,100 passengers dressed in their best holiday pajamas.  The non-stop, hour and fifteen minute train ride departed from the Malden Center Commuter Rail Station and made stops picking up passengers at the Melrose Cedar Park Station and the Reading Depot Station.
Over 65 student volunteers from Malden, Melrose and Reading High Schools spent the day as Santa’s elves, enchanting the children with their magic and enthusiasm.  The children enjoyed a visit from their favorite cartoon characters that came to life especially for the ride.  Elmo, Winnie the Pooh, Tiger, Frosty the Snowman, the Cat in the Hat and Rudolph the Red Nosed Reindeer helped celebrate the much anticipated visit by Santa Claus.  After a reading of “The Polar Express” by Santa’s elves, cookies and milk were served along with a gift bag and a coloring book!  The children sang along with the holiday music, drew in their coloring books and in keeping with tradition, each child received a silver bell from Santa’s sleigh.

The VNA of Boston’s ability to care for our communities most vulnerable members is highly dependent upon the success of annual fundraising events like the Holiday Express Train Ride.  Last year, through the generosity of our supporters, our Free Care Fund allowed us to care for 500 patients without insurance or resources to pay for their care.  Additionally, our Maternal Child Health Program provided direct care and specialized support services to almost 2,400 children and their families, making it one of the largest programs of its kind in Massachusetts. 


Thursday, December 2, 2010


Yes, it's been a long time...

No, this blog isn't dead...

Thanks for your emails. Lot's happening here in the real world... but know that more posts are coming soon.



- Posted using BlogPress from my iPad

Thursday, November 18, 2010

The Classical Music of our Generation?

Nearly 50 years later and still so, so good.

Here, Sir Paul is joined by a collection of high achieving buds.

Death panels?

You may recall that during the recent prolonged health reform debate, opponents of the then proposals cited the inclusion of "death panels" as Federally mandated authorities who could deny Grandpa necessary care and instead, send him off to die in a, perish the thought, hospice.  Unfortunately, a debate that focused on governmental empowerment cast an unfavorable light on hospice care.  That was most definitely unfortunate.

Yesterday's Boston Globe included a piece regarding the significant (and concerning) finding that where you live makes a material difference to where you'll die.  And despite the fact that 80% of us would prefer to die with dignity, with the ones we love, and at home... in some locations that's less likely.  According to the article:
Researchers at the Dartmouth Atlas Project in Lebanon, N.H., analyzed the records of 235,821 Medicare patients ages 65 and older who died between 2003 and 2007. Overall, the researchers found that one-third of patients spent their last days in hospitals and intensive-care units. But there was a big range. At one end was Manhattan, where 46.7 percent died in the hospital. In contrast, 7 percent of cancer patients died in the hospital in Mason City, Iowa.
While chemotherapy and other aggressive procedures can prolong life and enable some cancer patients to return home and to work, studies have shown that these treatments have little or no value for frail elderly patients and those with advanced cancer. But 6 percent of patients received chemotherapy in their last two weeks of life, and the rate was much higher — more than 10 percent — in some places, the researchers found.
Similarly, more than 18 percent of cancer patients were placed on a feeding tube or received cardiopulmonary resuscitation in their last two weeks of life in Manhattan, compared with less than 4 percent in Minneapolis.
Use of hospice care also varied a lot. In at least 50 academic medical centers, less than half of patients with a poor prognosis receive hospice services, the researchers found. And in some hospitals, patients were referred to hospice care so close to the day they died that it was unlikely to have provided much comfort.
Some of these findings are understandable.  Hospitals and the physicians who work there are driven to heal and to save lives.  In the distant past, most of us expected that we'd someday die in a hospital.  Today, we'd rather not.  In the not so distant past, referrals to hospice were greeted by patients and their families as admissions of failure and generated disbelief and denial.  Fortunately, that is changing as a growing proportion of the public has positive hospice experiences with loved ones.

To learn more about hospice care, click here or call 781-569-2888.

Tuesday, November 16, 2010

Beatles on iTunes today!

This is my bank account talking:

Compassion counts...

... because it's not only nice, it's also necessary.

We've all been patients.  We've all experienced, hopefully, the warmth of an empathetic caregiver.  The confidence that comes from knowing that the clinician before us is actually listening to what we're saying.  And the reassurance that comes from seeing that the information is being properly recorded somewhere so that others won't need you to repeat your entire story, word for word... five times.  Put that all together, and it's the value of compassion.  Unfortunately, most of us have experienced the exact opposite too. 

See today's piece regarding The Schwartz Center survey of patients and physicians on this topic.  Here's the link.

According to the article:
Dr. Beth Lown — a Mount Auburn Hospital internist and medical director of the survey’s sponsor, the Schwartz Center for Compassionate Healthcare — said she was encouraged that most doctors thought such factors could make a difference in whether a patient lives or dies.

“I think this is a knockout,’’ she said in an interview. Some “doctors feel that medical skills and scientific knowledge are the only things that turn into good outcomes. . . . I think all patients have always wanted emotional support, but it hasn’t always been in the doctors’ lexicon.’’

The survey found that doctors and patients agree on the importance of most but not all components of compassionate care, which include showing respect, listening attentively, giving information in a way that is understandable, involving the patient in medical decisions, and treating the patient as a person and not a disease.
As we continue (and for largely good reasons) to further specialize our health care industry, we also continue to depersonalize it as well.  With more and more pockets of capabilities emerging, the gaps between those islands can grow and widen.  Systems of care which emphasize filling those gaps and ensuring the highest levels of compassion will emerge and win in this rapidly changing industry.  Expect studies such as the one cited here to continue to punctuate this point.

Thursday, November 11, 2010


Holiday Express Train Rides Again!

One more announcement for today.  This one fun:

It may still be a bit warm outside, but the VNA of Boston is looking forward to snow covered lawns, red noses and Holiday cheer! On Sunday, December 5th we will once again board the Holiday Train to the North Pole for the 17th Annual Holiday Express Train Ride and would like to invite you to join us for this magical journey!

Each year, more than 2,000 children, parents and grandparents from Malden, Melrose and Reading chug along on a magical train ride to the North Pole. This cherished annual community event features the much-anticipated reading of The Polar Express by elves from the North Pole, gifts and treats, and Santa himself.

If you would like to be involved with the Holiday Express Train Ride, please consider placing an ad in the Coloring Book which is distributed to each child and kept as a keepsake by parents. You could use this opportunity to advertise your business or feature a coupon or sales event. The goal of the event is to raise vital funds for our Maternal Child Health and Charitable Care Programs, which provide home and community-based care to the most vulnerable and needy children and their families in the areas of maternal child health, infant and pediatric care, early intervention for developmental delays and social work support for at risk families. Please call the Development Department at (617) 886-6460 with any questions or to learn more about how you can get involved in this wonderful annual tradition.

A new educational partnership

The VNA of Boston is partnering with Simmons College with the “Partnership for Advancing Home Care Education and Practice.” The two organizations hope to both educate and train home health professionals for the future and advance home health care practice and education – all ultimately intended to improve care for patients.

“Through this partnership we can access resources and experts at Simmons who can help us translate research into clinical practice to improve outcomes,” said Adele Pike, Director of Education at the VNA of Boston. “Our staff may also have the opportunity to collaborate in research and quality improvement projects with the school.”

Currently, staff from the VNA of Boston is working on a web-based home health care library for Simmons’ faculty and students. Simmons students can participate in the VNA of Boston’s CareLinks programs, which provide clinical placements for the students and enhances the agency’s presence in assisted living facilities and elderly housing programs throughout Boston. Pike concluded, “It’s a win for us, for Simmons, and ultimately our patients and our community.”


As recently reported in our Homecoming newsletter:

The VNA of Boston is committed to providing the residents of Greater Boston with efficient, quality, patient centered care. To better serve our community and some of the high risk health problems it faces, Clinical Centers of Excellence (CCEs) were established with focuses in Cardiopulmonary Disease, Diabetes, Maternal Child Health and Wound Care.

Our clinicians care for over 12,000 patients each year. Over 2,900 of those patients have cardiopulmonary issues, 2,600 struggled with diabetes, 2,582 are new mothers and more than 3,000 needed assistance with wound care.

The creation of CCEs will assist us in improving clinical outcomes by ensuring that the care we provide is based on evidence and is continually improving. In each of the next four issues of Homecoming we will go into more detail on each of the CCEs.

Sunday, November 7, 2010

A sign of our times

I'd bet good money the Windows Phone isn't much to write home about, but this commercial?  Simply brilliant.  And a true commentary on life in 2010.

sometimes, the sky

Friday, November 5, 2010

another look see

iPad and Modern Medicine

I've been touting the many endearing characteristics of the Apple iPad since it's launch earlier this year.  A few recent reports have noted that the iPad comprises over 95% of all tablet sales (can you even name another tablet on the market?) and industry analysts, Gartner, is recommending that businesses quickly deploy iPads (see article here).  According to Gartner:

The iPad is further portrayed as having "the potential to be hugely disruptive" to both the markets and business models of various enterprises. Aside from book and magazine publishers, Gartner posits everything from architectural firms and schools through to airlines and hospitals as being affected. "While there are no certainties, the iPad looks set to become a market-disrupting device, like the iPod before it," says Prentice. "Even if you think it is just a passing fad, the cost of early action is low, while the price of delay may well be extremely high."
It seems natural that iPads would find their way into the health care industry and has recently pointed out, with some caution, that the trend has started.

Launched in April, the iPad continues to make waves across the world. Technophiles, teenagers and grandmas alike love the iPad, which has been touted as the tool to mobilize business users. Apple has sold about 8 million, with many physicians among those who have been bitten by the iPad bug.
In a February survey by Epocrates, 20 percent of U.S. physicians planned to buy an iPad. A larger group, however, remained somewhat cautious; 38 percent of physicians expressed interest in the iPad, but wanted more information to solidify their purchase decision. 
... and... 

This fall, Stanford University in Palo Alto, Calif., equipped 98 incoming medical students with iPads. The main goal is to improve the student learning experience by giving them flexible access to content whether it is a virtual cadaver in the dissection lab, annotated lecture slides and videos in the classroom or journal articles for evidence-based practice in clinic.
The medical school has not yet determined the practical impacts of the project, but pioneers point to its potential. 
See the entire piece here.

Thursday, November 4, 2010

The bad news keeps coming...

The final rule from CMS has been published and it's not good.  If you're following this blog, you no doubt understand that the home care industry has experienced deep cuts to Medicare reimbursement.  Despite valiant advocacy efforts, the most recent ruling contains more bad news.

This is a press release from the Visiting Nurse Associations of America:

Washington, DC – November 4, 2010 – In the final regulations on the Home Health Prospective Payment System Update for CY 2011, the Centers for Medicare and Medicaid Services (CMS) mandated cuts that exceed those legislated in the Affordable Care Act (ACA). Medicare home health provider rates will be cut across-the-board approximately 4.89 percent or $960 million in 2011 alone.

“Nonprofit home health providers simply cannot sustain this level of cuts and maintain the healthcare services that vulnerable patients rely upon,” stated Andy Carter, VNAA President and CEO. “VNAA worked hard to negotiate with Congress healthcare reform provisions designed to protect vulnerable patients from devastating cuts to Medicare home health reimbursement over the next ten years. We are disappointed that CMS has regulated additional Medicare cuts beyond the Affordable Care Act.”

VNAA is encouraged that CMS provided some flexibility on the requirements that home health and hospice patients must visit their physician or authorized practitioner in order to be certified for home health and recertified for hospice. For home health, CMS allows the visit to have taken place up to 90 days prior to the start of care instead of 30 days, as originally proposed, if the reason for the visit is related to why the patient needs home healthcare. If not, CMS will allow the visit to occur up to 30 days after the start of care instead of just 2 weeks, as issued in an earlier proposed rule. For hospice, CMS will also extend the timeframe for an in-person visit with a physician/authorized practitioner from 2 weeks to 30 days to recertify for hospice.

Many of the changes in the final regulations are designed to require providers to jump through hoops in an effort to address growing concerns about fraud and abuse in the Medicare home health benefit. Nonprofit home health agencies fully support federal action to thwart fraud and abuse but are concerned with the burdens placed on patients to meet the physician/practitioner visit requirements. It is very difficult to transport homebound patients to see their physician.

VNAA has developed concrete recommendations to reduce fraud and abuse in ways that do not incur significant burdens to reputable providers or patients. VNAA has also recommended CMS implement a temporary moratorium on new Medicare home health providers. (VNAA’s recommendations can be found at

“VNAA urges the federal government to exercise its power to establish a temporary moratorium on new Medicare agencies to put the brakes on fraud and abuse rather than mandate across-the-board cuts through legislation and regulation. Nonprofit home health agencies are already struggling and these additional cuts make it even harder for them to serve as a safety net in their communities,” stated Carter.

Emily Swanson
Visiting Nurse Associations of America

About VNAA: VNAA is a national association that supports, promotes and advocates for community-based nonprofit home health and hospice providers that care for all individuals regardless of complexity of condition or ability to pay. They provide comprehensive services for Medicare, Medicaid, uninsured, and privately insured patients. VNAA members share a mission to provide cost-effective and compassionate care to some of the nation's most vulnerable individuals, particularly the elderly and individuals with disabilities. Visit today.

Friday, October 29, 2010

the setting

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Our annual tradition...

The company you keep

I remember a lesson my own mother taught me years ago.  As a child, I was lamenting my own lack of progress in improving my competitive basketball skills and her simple but high impact advice was: "If you want to become a better basketball player, make sure you play with people better than you are."  Upping your game happens when, in the case of basketball, you compete against higher calibre players.  It's a compelling lesson about role models and pushing yourself beyond your comfort zone.

Earlier this year, I had an opportunity to meet the CEO and CFO of the VNA of Central Jersey.  The initial conversation with Mary Ann and Kevin pertained to some information system issues they had been grappling with, but then eventually covered a broader range of topics.  I made a mental note that a follow-up and more in depth discussion might be helpful.

Yesterday, in a high rise office building overlooking the sun soaked southern tip of Manhattan, members of our respective teams had an opportunity to have that discussion.  The impromptu cellphone photo above includes the participants.

VNACJ, like the Visiting Nurse Association of Boston, is a 100+ year old organization (actually, they are celebrating their centennial anniversary this coming year) with a mission and quality focus.  Like the VNA of Boston, they experienced financial hardship some ten years ago after the Feds radically restructured the Medicare reimbursement system.  And like the VNA of Boston, they have persisted and adapted and grown.

Our conversation covered a very broad range of topics, including strategy, operations, policy, communications, financial, marketing and sales, and information technology.  As noted previously and frequently in this blog, the home health care industry will be undergoing significant financial and other challenges in the coming few years and learning from colleagues who are tackling the same challenges has proven to be a helpful and, in some cases, eye opening experience.  We're most thankful to our friends in New Jersey for taking the time to meet with us and for hosting such an informative and enjoyable event.  It felt like time well spent.  And it reminded me of my mother's words from years ago...

Wednesday, October 27, 2010

The churning...

The above was sent to me by my friend, Gerry... and it got me to thinking.

I have a London Fog rain coat I purchased in the early 1990s and I swear it looks as good as the day I bought it.  We have a second refrigerator in our garage and it's 26 years old and working perfectly.  There's a TV set in my house that's also 26 years old and it's not going into the dumpster until it dies.

Now as for electronics gadgets (phones, computers, cameras, etc.), none of the ones I use are much older than a year or two.  The problem is that the technology keeps getting better and cheaper... and newer and flashier alternatives are always being announced and brought to market.  And once they get there, the prices precipitously drop and quickly.  Thus creating the churning.

If you type "iPad" into the search box on this blog, you'll see that I've written affectionately about mine on many occasions.  It's a real life changer and I love it.  Or loved it.

The problem?

This is the recently announced 11 inch screen Apple Macbook Air.  It's just slightly more expensive than the highest end iPad, but this is a real computer.  Full Mac operating system.  Full keyboard.  But still light and tiny. Long battery life and instant on.  A person could dump the laptop and the iPad and converge into this one device.  On the surface, it makes a ton of sense.

But, churning does not.

Dan Gilbert speaks about "what makes us happy?"  Hint: it's not having a lot of choices.  Here's the link to his 21 minute video.

When you focus on the tool, you can lose sight of the task.  Case in point: newer and better digital cameras do not, for the most part, improve the quality of the craft.  Newer and better digital gadgetry does not, for the most part, alter the prospects of success in creating the manuscript, balancing the checkbook, presenting the slideshow, browsing the web, answering emails.... or whatever it is that you do on that device.

There is an entire movement dedicated to the less is more school of thought.  Online booksellers are full of guides on how to simplify your life and based on their sales stats, it looks as though many people are reading them.  

Wonder what you think about it.  Feel free to comment...

Tuesday, October 26, 2010

Fence sitting and social media

About a year ago, I jumped head first into the world of social media, starting this blog, tweeting, blipping, facebooking and connecting with everybody I've ever met via linkedin.  My thought was that although I wasn't clear whether social media ultimately will prove out as a valuable tool... or whether we'll look back upon it the way we do bell bottoms and mood rings, it was worth a try.

After about six months, I made an assessment by looking at google analytics data and it confirmed that there was enough value in the blog to continue and that the other social media tools helped support it.  Employees here read the posts and people from around the industry check in periodically as well.  On occasion, I receive emails from people looking for health care services, which is the most gratifying and important reason for continuing.

But I do find myself more often than not thinking about that mood ring issue and sitting upon a fence regarding whether this is worth a continued investment of time and energy.  Here at the VNA of Boston, I gain a range of reactions that literally run from "total waste of time" to "I read your blog every day... keep it up."

This morning, I attended a breakfast presentation hosted by our friends at Solomon McCown.  The focus was on crisis management in the age of social media.  The panel included Linda van der Pool as moderator (Boston Business Journal), Perry Hewitt (Harvard University), Brian Leary (McCarter & English), Ashely McCown (Solomon McCown), Jeff Moriarty (The Boston Globe), and John Pepper (Boloco).  In short: their comments pushed me off the fence and toward a fuller embrace... for a while at least.  Here are some of the more interesting points:

Ashley: Johnson & Johnson will be long remembered as a company that managed its crisis (tainted Tylenol) with success.  Immediately after reports surfaced of trouble, employees took to the streets with megaphones warning citizens to return all product.  Boy Scouts were deployed in service projects to churches and other settings to get the word out.  The CEO was highly visible and immediately so.  BP will be long remembered for its failure.  It took seven days before the company tweeted on the issue.  The CEO?  Gone.

John: It's important to be authentic, real.  There's so much pablum out there, you can only stand out if you're interesting.  His goal in social media is to be "a little off center."

Perry: You may be conspicuously absent if you don't engage in social media.  An unhappy customer may post something negative on YouTube, so it's vital to post your counterargument right there next to it.

Ashley: It takes time to build loyalty.  The time to do it is before the crisis.  Toyota had 81,000 Facebook friends at time of the first recall.

John: It's not about the number of Twitter followers.  "It's about the quality of the listening."

Ashley: Asked about the risks of social media, she noted that "there is more risk in not doing it."

Jeff: One risk is that someone can impersonate you or parody your company.  Active and effective countermeasures need to be developed.

Brian: 53% of HR reps check Facebook status to vet candidates.  Watch what you post there.

Now before I forget, let me go tweet about all this...

When David becomes Goliath

This was a fascinating and exceptional commercial back in the early 1980s when Apple Computer was trying hard to fight the massive market dominance of Microsoft and DOS/Windows-based computers.  Touting their "better" technology, they tried hard to combat the perception that the monolithic giant had played mind control tricks on the general public.  Here comes the bright, colorful, attractive, speedy, powerful... Apple to throw a wrench, or more specifically, a sledgehammer, into the face of Goliath.

A quarter of a century later, Microsoft appears to be back on its heels, fighting the internet juggernaut called Google and the technology maven called... Apple.  Apple's iTunes distribution channel is one of the most powerful and ubiquitous in the world.  Their iPhone just surpassed Blackberry in terms of world market share, iPad is the fastest selling device in history and Macbooks are beginning to outnumber Windows computers on college campuses.

Microsoft has got to be worried.  VERY worried.  Their Windows 7 OS has tried to correct the perception of mediocrity while they have focused on fixing their gaming system (XBox) quality control woes.  But, it is clearly struggling.  For them to survive (yes, survive), they need to correct the inadequacies of their technology first.  But then, they need to cast Apple as the new Big Brother and hit away.

Meanwhile, Google watches...


- Posted via BlogPress, iDevice

Monday, October 25, 2010

Highland Home

Yesterday's Boston Sunday Globe (see here) featured the Visiting Nurse Association of Boston's very own Jenny and Colin Highland, describing them as "ardent do-it-yourselfers."  In addition to bringing their talent and skill to patients in and around the Boston area every day, these young parents have been very busy decorating, fixing and restoring their home.  According to the article: "One peek inside their 1920s Colonial-style house in Milton, and you get the message that something special has gone on."

I had an opportunity to conduct a few home visits with Colin last year and had no idea that he is "a Renaissance-type man who’s an artist (landscape canvases), woodworker, carpenter, gardener, and poet."

Well done to Jenny and Colin!

Tuesday, October 19, 2010

The VNA of Boston is Elite!

From an email just sent to all of our employees:
I am pleased to announce that the VNAB has been once again named as an Elite Agency by OCS HomeCare. The HomeCare Elite identifies the top 25 percent of agencies with winners ranked by an analysis of performance measures in quality outcomes, quality improvement, and financial performance. As a 2010 HomeCare Elite agency the VNAB ranks among other leading home care providers across the country.

Amanda Twiss, CEO of OCS HomeCare had this to say: “The 2010 HomeCare Elite winners continue to demonstrate a commitment to providing their patients with the best possible care while performing at the highest level. We congratulate the VNA of Boston on being one of the top home care agencies in the country.”

We have decades of experience as a leader in home health care --- providing excellent care to all who need us. It is because of YOU, our incredibly skilled and dedicated nurses, therapists, social workers, administrative and professional support staff that have gotten us to where we are. I firmly believe that it is the excellent and high value care that you all provide that is critical to the success of reforming our health care system and we should be proud to be a leader in that effort.

As you all know, we recently kicked-off our 125th Anniversary with our Heroes in Home Healthcare Gala. I would like to share with you what I mentioned to our guests that night:

“125 years ago, by the harbor in Boston, a revolution began. A revolution that blazed across this country in the name of teaching, healing and advocating for those who ‘fall through the cracks’. We’d love to celebrate this evening a world where cracks such as these no longer exist. Where a compassionate society has adequately reformed its system to allow for high quality health care services to be available to all of its most vulnerable members... and where better performing, more conscientious caregivers are rewarded for investing in programs and improving lives.”

As a 2010 HomeCare Elite the VNAB IS being recognized and rewarded for your hard work. There is still much work to be done and cracks still exist, but each day we work towards making them smaller. On behalf of the VNAB and the patients you serve every day THANK YOU.


Monday, October 18, 2010

35 years ago... this very minute

Received a call from my brother tonight asking if I had any idea what the two of us were doing 35 years ago tonight.  Based on an announcement on the classic rock station in town (verified via a google search later), we were able to confirm that precisely 35 years ago this very evening, we attended a Boston Garden Jefferson Starship show.  Anybody remember Grace Slick?  

Stands out for me because it was my very first live show and I was rabid about the Starship, most especially about the particular song linked below (this vid appears to be an '80s rendition).  Memorable also because of the opening act.  This Boston show was just before they exploded.  Stevie Nicks and Lindsey Buckingham had just joined the struggling Fleetwood Mac and released a new record.  I remember being impressed by the mysterious, swirling Nicks and the maniacal guitar playing of Buckingham.  I proceeded to buy their "new" self-titled album within days of the show.  That album stood for thirteen years as the longest running number one album on the charts.


Sunday, October 17, 2010


Clark's Pond

Less and less likely

Despite Liam's note that "we'll see ya again in some other world, another time" at the end (as best I can make out - I can understand him perfectly when he sings, but not at all when he talks), a reunion tour seems less and less likely.  It's the Noel-Liam love-hate relationship thing.

Too bad, though because if you've never seen Oasis live, you haven't been to a live show.  Mate.

Saturday, October 16, 2010


Consider this a classic Before and After.  I've recently become fascinated by the aging process and as I stumbled upon Mr. Joel singing his break-out hit when it was brand new and then again more recently, I was struck by the visual (and audio) impact of 33 years...

Wednesday, October 13, 2010

The high cost of cutting costs...

I had an opportunity to attend a Boston Chamber of Commerce breakfast meeting this morning, featuring the four candidates for Massachusetts Governor.  In attendance: Charlie Baker, my old boss at Harvard Pilgrim, Deval Patrick, current governor, Tim Cahill, the recently controversial independent conspiracy theorist candidate, and... ah... the other one.

The other one is Doctor Jill Stein who is running as the Green-Rainbow Party candidate and who has absolutely no chance of winning.  As such, it's very easy to dismiss the perspective she brings to the race.  But this internist, community adovcate and respected author actually adds an important voice and I for one was interested to hear what she had to say this morning.  And although she received no applause (as did the current Governor when he dropped a very stirring "this is a profound distraction" remark related to the allegations that former Cahill operatives were working with his own campaign to undermine Baker's efforts) and her turn at the mic often felt more akin to a polite obligation than an opportunity for the audience, she did make one very interesting point. 

Dr. Stein's platform includes a proposal that the current Medicare system for seniors be converted into a national system for all populations.  Citing the fact that "this system just works" and cuts administrative hassles, she compared the 250 "workers" at Massachusetts General Hospital to merely 3 at a similarly sized hospital in Toronto.  The 250 at MGH sort through the multitude of requirements and paperwork associated with generating clean bills and pursuing payment for services rendered.  In Canada, that work takes just three individuals, leading to, per this candidate, a greater ability to apportion the funds toward medical care or savings.

It's an interesting point.

Managed care was designed to, among other things, control the growth of medical spending.  In our own agency, the number of individuals who oversee our managed care operations outnumber the resources devoted to other much, much larger payers. 

The new, emerging health care system contains provisions for the creation of new accountable care entities, pilot payment reform programs, and quality-based reimbursements.  The goals are to improve care while expanding access.  Oh yes... to cut costs too.  To Dr. Stein's point, if administering these programs becomes overly complex and the documentation demands expand (as we've recently seen in home health care with the adoption of tighter and more complicated OASIS requirements), then savings can rapidly evaporate or even reverse as the MGH-Toronto hospital example highlights.

Cutting costs is good.  Adding administrative burden... not so good.

Sunday, October 10, 2010

One for a Sunday morning

I'm a sucker for catchy pop tunes that make me play drums with my index fingers on the top of the steering wheel.  Here's the latest culprit.

And a nice message about the enduring power of that which endures.

Friday, October 8, 2010

This is what Quality looks like...

Good news about our private care company.  For more information, click here or call 781-431-1484.
Wellesley, MA – VNA Private Care, a private-pay home care agency based in Wellesley, MA and affiliate of the Visiting Nurse Association of Boston is among the first in the state to earn Accreditation from the Home Care Alliance of Massachusetts. The alliance, which represents 170 home health and elder care agencies across Massachusetts, has created an accreditation protocol to promote quality services, ethical business standards, and superior employment practices in an industry that lacks meaningful licensure in the Commonwealth of Massachusetts even while it grows in popularity.

“We are proud to be in the initial group of home care agencies earning this accreditation demonstrating VNA Private Care’s commitment to quality,” said Rey Spadoni, President and CEO of the VNA of Boston and Affiliates. “Peace of mind for our clients is paramount and this accreditation from an independent expert will help promote the advantages of keeping people independent in their homes and communities with the superior care we provide.”

The Home Care Alliance launched this Accreditation Program for Private Pay agencies (agencies that are not paid by Medicare or Medicaid), in July. Agencies seeking accreditation are required to submit documentation to show that they meet standards established by the Alliance.

The standards were developed over several months in consultation with 14 agencies throughout the Commonwealth. Training requirements, administrative protocols, and business practices are among the categories that the Alliance reviews for accreditation.

“We wanted to provide leadership for an area that is becoming more and more important to the health care delivery system in Massachusetts,” said Patricia Kelleher, Executive Director of the Home Care Alliance of Massachusetts. “These standards highlight our agencies’ best practices, and will help guide members of the public as they choose who will take care of their loved ones in their homes.”

Rationing is bad, bad, bad...

(photo courtesy of

Highly successful businessman and founder of Staples, Tom Stemberg, made some interesting comments recently regarding the United States health care system.  The Boston Herald, from which this post is drawn, recently wrote about this here.

According to Mr. Stemberg:
I think we have to confront a very unfortunate reality in this country: We’re doing a tremendous amount of elective surgery on people for whom that election probably is no longer affordable.

If a citizen is 80 years old and wants to have elective surgery, knee surgery to pick an example, because they think an artificial knee will help them walk the golf course better, they should have every right to do it, but they should be paying for it. The national government should not be paying for those kinds of things
We used to have an active and vibrant and moderately successful phenomenon in this country called managed care.  Providers were paid a capitated (usually severity adjusted) monthly payment to take care of an entire covered population's health care needs.  Because additional cost savings could be derived by "carving out" specific categories of care (it all began with mental health services, then pharmacy benefits were next, followed by diagnostics, and then...) and businesses didn't want to restrict (er, ration) care to employees, it all fell apart.  There was a public backlash against managed care as being overly restrictive and perennially penny pinching and so, that phenomenon gave way to a return to fee-for-service health care. 

During the recent health care debate, mere suggestions that empowered governmental (or even private) bodies would review and make recommendations regarding coverage options and treatment protocols raised cries of "rationing" and "death panels" and so many of the most restrictive components of the bill were pared back.  Let's face it: we just don't like rationing... or anything that even remotely smacks of it.

Unfortunately, while the expansion of coverage provisions go into effect right away, health reform legislation has the cost control provisions being phased in over time.  Some provisions call for changes in how providers are paid, setting up quality-based payment mechanisms and new accountable care organizations designed to capture the full and global payment to cover services for a defined population... much as capitation was designed to do in the former system.  As has been discussed here, we'll need to make sure we understand and avoid the pitfalls of the past as we build the next system.

Now back to Mr. Stemberg.  I wonder how his comments cited above will play to a population totally and completely unwilling to entertain any system that even remotely involves rationing.  It could be argued, particularly if you're the 80 year old golfer he mentions but who can't afford a new knee, that a loss of Medicare coverage for said joint replacement surgery is going to feel a lot like rationing... particularly since you can get that knee covered today.

For the health care provider community, which is perceived as being largely inefficient and, in some cases, profoundly greedy, the cost cutting measures of health reform legislation need to be about more than an endless stream of straight reimbursement cuts.  Many of us have driven ourselves hard to become lean and no one would accuse the organization I work for as being greedy.  Just the same though, we're expecting nearly 5 percent cuts each year for the next several.  Those are cuts we know we can't sustain.

No rationing.  Full coverage for everybody.  Unrestricted access to every provider.

It just won't add up.


Wednesday, October 6, 2010

Six from Big Texas

Comments from the National Association for Home Care & Hospice in Dallas forthcoming.  In the meantime, some images...