Life in the Medical Maze

Yes, Petie, I envy you and Karen (the OTR who also is a CDRS (cert driving rehab specialist), having had the years you did to enjoy the relative greatness of the medical system back when things were different. Like you, I also chose OT in my adulthood, and graduated when I was 36; I completed internships on 12/20/96, I believe, a Friday.  I started work that afternoon, having been hired to be an OT in a little 'nursing home' (SNF for "Skilled Nursing Facility") in a suburb on the west side of Denver.  The job was with a huge contractor to facilities, the biggest in the nation at the time: Novacare; they had well over 100 therapists in the Denver area in their division that contracted with skilled nursing facilities to provide therapy services.  

My manager was a young PTA (Physical Therapy Assistant), who had come up through the ranks being educated in the military, where they don't segment OT and PT so much, so she was actually a very uniquely talented person!  I remember the first day, since I had ZERO education in OT school about Medicare billing, and had done internships at the Denver VA, so I didn't get training in insurance billing there either, I hopped in her car to run downtown and take something to her husband at his work, stopping to pick up antiperspirant on the way as she had forgotten to do that at home getting her kids and herself and her husband out the door into Denver traffic for their days.  She was literally driving on a busy city road, putting on underarm product and talking about Medicare when she took a call on her cell phone! That was my first official meeting as an OT!  WELCOME TO THE CRAZY WORLD OF THERAPY, should have been on the visor of the car windshield!  

At the time, I did not know I had fibromyalgia, and I'd actually gotten much healthier when on internships at the Denver VA, I'd found out what I was allergic to food-wise and had changed my eating and had a really good balance in life in Denver while on internships; 8 hour days and I lived a block from the facility and could get up at 7 and be to work at 8 am. The work flow was reasonable and while it was challenging to learn about physical disabilities therapies or psychiatric care when on the locked unit, I felt supported and safe at work and when I'd go home on my 'free time' I took with me a sense of well-being and optimism about my present and future days.  

That has not been the case overall working in insurance-based environments, and that is why I have been wanting to have these conversations on Lumigrate in order to educate the public, or let other providers read 'this middle aged-old lady's' experiences and hope we can get to solutions in the future times! These are encouraging times if you look at that there ARE new programs spouting up, such as the Patient Centered Medical Home model that I've referred to a bit on Lumigrate and hope to cover more about as that model rolls out in the United States after a successful trial in Grand Junction and a few other centers of medical innovation in the country. 

It was 'suggested' by my supervisor for my first full day of work, that I get three women patients ready for breakfast, which was served at 7 am, as two were roommates and one was right across the hall.  Now, what's your impression of that, Petie?

Here's mine, now that I've had experience and can look back on my formative days -- as you said, above, HOW is it ethical to be billing for 'therapy' when you're getting three people dressed in the morning to go to breakfast? WHOSE best interests is that serving?  The facility's, as they don't have to hire another CNA if they can have the contract OT billing insurance for time doing basically CNA work! Is it in the patient's best interest?  Would YOU like me coming in at 5:30 in the morning to get you up so you could get pushed in a wheelchair to breakfast at 7 am? Or would you do better AFTER breakfast, when you were awake, having the opportunity to be up and moving and doing an activity such as standing with the walker to brush your teeth or do exercise which would allow you to, later on, be able to get up and dressed on your own safely? People need to practice using reachers and can do that in the afternoon in a FUN way and then it's a LOT easier to have them put on their pants and shoes using the adaptive equipment after that.  

It wasn't good therapy and I knew that at an intuitive level but that's not what my supervisor/mentor was teaching me!  So think about the difference between what Petie's first work experiences were for supervision and training/mentoring and what mine were, we're exactly a 'generation' apart in age.  (In the years Petie went back to school to become an OTR, my mother was going to school to become a teacher and interestingly worked in sensory integration exercises with her class every day, as the students needed it and weren't getting it even with the good funding of those days -- again, all the systems have very long histories leading to the 'failures' we are dealing with today, 40-50 years later!)

So, Petie, if you end up having a surgery or an injury or getting sick and needing to go to subacute rehab at a skilled nursing facility, THAT is why I won't be there working anymore.  I hope this conversation helps people to understand what is going on in health care today, and why many of us are not working with patients, who are very experienced and 'good' therapists! Recently, one of the hospitals here layed off a lot of the therapy staff, and it seemed to be the ones that were there the longest and likely were up higher on the pay scale.  That's really sad for them and their lives with mortgages and lives set up after years of dedicated service, and it's also sad for the patients and therapy teams who won't have that fund of knowledge to pull from anymore. 

I also recently had a conversation with someone in the public who has health challenges who have devastated her finances and life and she seemed bitter toward medical providers; I think many see the bills and presume we're still 'on easy street' with what we receive in pay or revenues; that has not been my experience.  I know more medical providers and their families today than any time in my life and they all have comparatively big challenges with finances than in their past.  But in my opinion, you should not be asked to break laws in order to make a line item look right, you need to go about your business and let the managers and administrators know of the problem, appeal to your team for unity and support and hang in there together. And keep working that information up and up, including letting your lawmakers know! I've never had a work situation where anybody said 'let's get together and let the people in power know of our concern'. 

So I'm glad we're still 'hanging in' here at Lumigrate at least, Petie.  Thanks for writing about the good old days and I hope my insights about the 'not so good medium days' help and we are all in the NEW days ahead that will offer solutions and get back to things being 'right with the medical world' and not be a maze that leads nowhere good.  I truly believe it is people like us who are going to be needing to be out there in the work environment and 'never completely retiring' like so many others, that are going to help provide some of the solutions, along with those who are younger and innovative, and those who are everywhere in between.  

~~ Mardy

Mardy

 Thank you for posting this. It is interesting to see both of your experiences about the OT field and how it has changed. I feel that all fields medical and education are failing as a result of paper trails and not spending enough quality time doing what we love.

I am sure you both love OT just as much as I love teaching. However, the teaching profession isn't what it used to be either. I spend so much time on paperwork and testing, and so many other law required things that I barely have any time to teach. It is heart breaking. 

I hope that we can change this around and figure something out. It is very discouraging for those of us going into the medical field or into the education field knowing we are not appreciated and people do not want to understand what we do. They do not realize that we touch people's lives and help them live, learn, and most times get control of their lives back.

Here is to positive thoughts for the future of medical and educational professions and to Lumigrate for allowing us to continue sharing and expanding our knowledge in both aspects! 

Mardy - GADS NO, I would not want you coming in to get me up and dressed doing therapy before breakfast to get me to breakfast by 7 am -- I'd HATE you, even though you're very likeable!  Maybe I'd let you come back later in the day and work with you .  Patients do understand that the terms of their being at the facility is they have to participate in therapies, since their insurance is footing the bill in most of these situations we're talking about here.  And I'm really enjoying reading what you write here as well, Faith, so thank you for reading and commenting on some of my articles. 

My comment from my perspective coming from 'the good old days': Generally speaking, therapists in the medical field are ethical people by nature and this was also drummed into us in school.  When assigned a patient for therapy, each disciplline spends time evaluating the patient.  We set goals for the patient to increase their function through what we do in therapy.  If the patient is able, they participate in formulating their goals and treatment to reach the established goals.  The goals are broken up as short term goals underneath long term goals, with an overall goal of treatment at the end of treatment, which relates to where they will reside and how much assistance they will require. 

I like the optimism of Faith's comment, above, about figuring this out together and hoping for the changes to come. That's why I like having the 50 year spread from her to your age, with me being right in the middle -- different perspectives, though I think we all remain overall optimistic despite much we go through that is very challenging individually and as part of society in the US today.

Not to say they're well managed in all departments and there were such 'turnovers' going on due to the stresses put on these businesses for so many years now, and it just keeps getting harder all the time to 'make a buck', but overall the entities are good entities and eventually get back on track it's seemed to me.  

Important to note, that was before PPS and when Medicare was 'the cash cow', where treatments like this were leading to huge abuses of the Medicare system.  Medicare's brains announced PPS and it was so drastic a cutback it unemployed many therapists: I went from working overtime to having 8 hours of work a week spread out between two cities an hour apart, as they were trying to keep the hundred+ therapists on and regroup on how to make money therapizing people in the new system of reimbursement.  

In order to have full time, they sent me here to western Colorado for two months to open a new contract they got and I could tell by the documentation by the outgoing OT in the outgoing contractor that they were 'cooking the books'... every patient did better on every goal every week, which even as 'green' as I was was clearly not reality!  They also all had eating goals and I went to the dining room at lunch and a staff member said 'it's nice to see an OT in the dining room for a change'.  So it's good to see that the companies have learned how to regroup, Medicare modified PPS and it is possible for therapy providers to do ethical, appropriate therapies overall, but the management has to be SO smart about how to look at the #s and who is going what and having sense about how each team is 'making things work'.  And that's where I personally have seen 'the breakdown' occur.  

Good for you for refusing to go back if you were being asked to do treatments that weren't appropriate -- that's the benefit of being older and 'established' and working 'PRN'/on call and not as you were many decades ago and were divorced with two little kids!  I believe you're talking about the little SNF in the Colorado Springs area that I'd been hired to be the primary OTR at and you agreed to come do upper extremity therapies PRN, and we found out later on the news they'd arrested the bookkeeper who had embezzled $900,000, using $100,000 of it on perfumes.  I signed the contract to work for the company that was a 'rebranding'/offshoot of a big provider who had gotten into trouble with Medicare, and was going to see if they wanted more facilities in Colorado.  So EVERYONE was a brand new 'team'.  

There was a big red flag off the bat, which was there were NO vendor relationships the facility administration could set me up with to get the needed wheelchairs, walkers, bedding, etc., to keep patients' skin from breaking down and allow for their best function and safety.  Lucky for them, I have good friends in therapy, like you and Jan Casserly of APA/ Affordable Positioning Alternatives, who 'came to my rescue'.  I started in May (of 2002) and after July 4 weekend I walked in and there had been a TON of falls over the holiday weekend;  the medical director was an MD who was also MedDir at other SNFs around town and the State comes around to each facility every year for their 'survey', and were focusing that year on wheelchairs having 'restraints' on them (seat belts can be used for pelvic positioning or misused/abused to keep someone in their wheelchair instead of figuring out other strategies.  In the old OLD days of 'nursing homes' there is a history of people being tied up, so there are many new and good rules the businesses in the business of taking care of people need to uphold.  

There is a 'window' for the survey to happen and it's done in a way that's very disruptive to providing patient care, but I can see how it 'has to be done' this way maybe; they swoop in unannounced and 'surprise' randomly some morning with a team of four typically and scatter down the hallways looking to find what the 'typical' morning routine is.  Then the staff has to respond to all their questions and if there are not adequate responses by the facility's staff, then it gets put on the list of 'deficiencies'/dings, which results in a plan of corrections. Then, what I've seen over and over again, the facility staff gets so stressed over all the reprimanding and 'shame' involved on top of the extra work involved in solving the problems they got caught on, that if it's not a good team involved or there are weak links on the 'chain', things fall apart.  For a while, and the inevitable turnover occurs, and hopefully they hire new and good people and they end up, in the END, better for it.  But if you're working there or a resident there, you go through a mess potentially.  

In the last facility you and I worked together, where I was the primary/full time OT and you were coming in PRN/on call to do treatments in your specialty area related to hands, I was doing a lot of sensible things that a manager would have done for the department, and had we had experienced area management who had a trusting relationship with the 'mothership' office in California, there would have been support for what I was doing as it was in the best interest of the facility, the residents, and was setting up a valid rehabilitation program within a facility that had been clearly ravaged by embezzlement and bad therapy provision by the previous contractor.  The nurses didn't even know how to request orders from the doctors, Petie! Lucky for you as PRN, you weren't having to interface with that.... there's a LOT of behind the scenes straightening out of things that are unbillable time and bring down a therapists productivity and to me it makes the most sense to have as much of that done by ONE person, as then you don't have to communicate with others about it and have things literally 'lost in translation', including lots of TIME.  Time is a valuable commodity, and therapy/medical is no exception to that rule!  Then the on call people come in, enjoy their work, want to work there, give good treatments and have good productivity if they are properly set up and supported.  

So I wasn't able to have good productivity within the three month window they gave because of all those factors and they fired me on a 'technicality' when I clocked out at about this time on a Friday (11 am) as I'd hit my forty hours for the week and they were not paying me overtime anymore, and I went back in to get my sunglasses and on the way out the nurse caught me with questions about the orders he needed to get for us ALL to be able to help the residents, bill insurance, make money for the facility who paid the therapy contract company and then paid us.  The area manager in Denver saw in her computer I'd called the mothership and clocked out but she'd heard I was just there (as she'd called as I walked into the office to get my glasses), and she called up to the administrator to ask if I was working and the administrator said 'she announced in the morning meeting she had to be done working and not bring her anything that can't wait to Monday and I see she's sitting in the nurses station right now' and when I left the administrator asked the nurse what we'd been talking about and since it was work-related I was fired for working off the clock.  

SADLY, while I was out signing up to work with those knuckleheads (who lost the contract before the year was up and never pursued having contracts in Colorado again I've heard), someone emailed me and asked me to work for them supporting and advising their team while she went through breast cancer surgery and treatment. And that brings up another topic for another day: the increasing split in the United States as there is a growing gap in the United States of the 'have's and the have nots'.  Like the 1960s and 1970s, the United States has a growing feeling of people fed up and stressed and the picket signs are increasing, the marches on Washington or state capitals are on the news and it feels like a tinder box where the match is out there and is about to be lit and up we will go.  It will be an exciting time and I'm glad we have coast to coast providers on Lumigrate, of all ages, ready to share here about the problems and solutions.  Thank you all for participating.  ~~ Mardy  

One of the benefits of having gotten out of college earlier along than you did was I was able to start my own therapy company and perhaps missed a lot of the things you were seeing because I ran an ethical, 'clean' business. One of the benefits of talking with people 'younger' or 'older' than you in a profession is you get the different perspectives of those who worked in different places and times.  

And  you're right, Faith's optimism is refreshing and a very good thing to see.

:)    Petie....the OTR