Doing Well By Doing Good

Like many home healthcare providers, throughout most of my tenure as a visiting nurse my compensation was fee-for-service. This meant that as business went up and down, so did my paychecks, and with the rocking and rolling that has characterized the industry, "down" often was more common than "up." As a result, most clinicians have had "side jobs," often with other home healthcare providers that needed flexible, part-time help. That way if their primary employers hit a rough patch or there was a downturn for any reason, they had another source of income to assure that mortgages would be paid, families fed, and other obligations met.

There came a point, though, where I accepted a salaried position with a large company, which also offered ample opportunity for paid overtime. The down side, as I later discovered, was extensive travel and excessive "on call" nights that put both my patients and me in jeopardy, because a chronically sleep-deprived nurse working long day after long day and then going out again at night is an accident or a serious mistake waiting to happen. While the money was good, it became clear that I needed to consider other options. What was less clear was what those might be.

At the very least, though, for almost a year I had not needed my side job, a part-time gig with a small, generally unremarkable home healthcare agency. Bottom line: I simply hadn't found time to stop by to resign.

One Friday afternoon my phone rang. It was the administrative assistant at that little agency, urgently seeking a nurse to manage some patients in my service area. At that point I happened to have the time but not the need for more work, with my primary employer offering all the overtime I wanted and at a higher pay rate. "Is the boss in?" I asked. "I'd like to speak with him."

"Sure," she said, and transferred me.

When he picked up the phone and after the usual pleasantries I got down to business: "'Barbara' needs help covering patients. My question is, why should I take any patients for you when I simply can take more with my primary employer, not have to deal with different paperwork or drop-off points, and make three dollars more per visit?"

His immediate response? "If they pay you three I'll pay you five!"

Now, five dollars above my current visit rate was a good deal. "That works," I said. "Transfer me back to Barbara, please, and I'll take some patients."

He did, and I did.

But it all had happened so quickly that I wanted to be sure he remembered and meant what he said. So a few days later while delivering some paperwork I popped into his office, and before I could raise the topic he produced the paperwork for my raise and handed me my copy. Point for him.

It only got better.

As we talked he said, "I want you to be a part of this company. Full-time, part-time, in the office, out in the field - you know I've offered you the Director position many times . . . " Indeed he had, and I acknowledged this with appreciation. It's not the kind of work I want to do any more, but that the opportunity was there certainly was clear. He continued, "In some capacity, I want you here!"

That was gratifying to hear, and I thanked him sincerely and left.

I like to say that it took me two weeks to realize that this was a human male saying, "Tell me what you want so I can give it to you," not a message I was accustomed to hearing!

"I wonder if he means it," I eventually thought. So I sat down, considered what I most would like to do in my work, thought about ways this might add value to that little company, and wrote a proposal.

Back to the boss I went, opening with, "What this company needs is a Home Healthcare Specialist - "

"Absolutely!" he exclaimed, cutting me off . . . and surprising me no end, because there's no such thing! I had made it up, taking my abilities and interests and crafting them into a job I'd like to do. Educated as a Clinical Specialist, I have the qualifications but cannot use that title because I graduated before Advanced Practive Nursing licenses existed and never bothered to grandfather myself. So I had made up a comparable title and tailored it to work I'd like to do in home healthcare.

Without even knowing exactly what it was, the boss signed on, and gave me a modest but not insignificant raise over what my primary employer had been paying me.

That little company was so small and, in my view, so precarious, that I actually kept my other job for awhile, cutting down to "as needed, registry" status, but still employed and so able to go back quickly should that be necessary. Indeed, I wondered if my paychecks for my new position would bounce. (They didn't.)

So there I was, with this new, undefined job and a title that was my own fiction and, as such, meaningless to everyone else. And the question became, How shall I earn my salary?

I considered what patients, doctors, and hospital discharge planners had told me over the years; what I had observed; who had stopped me on the street with what sorts of questions; what seemed to confound the efforts of others trying to do their jobs and what would make things better for them; what problems kept popping up over and over; what assumptions and rituals had been carried forward blindly whether or not they were effective, or as effective as they might be . . . and as ideas emerged I began to formulate a plan. A fanatic about people who are licensed to practice a profession actually doing so, whether or not they have non-clinical responsibilities as well, I continued to see patients while beginning to set other things in motion. That practice led to even more ideas.

People noticed. One of the most talented Physical Therapists I've ever known had signed on with this little company on a part-time basis, it being his "side job" as it once had been mine. Knowing his vision, his insatiable curiosity, his openness to new possibilities, and his phenomenal clinical acumen, I created a "Rehabilitation Specialist" position that was as undefined as my own role, and he came on board full time, too. On a very small scale we began putting specialty service lines and programs in place, and people began noticing even more. Stellar clinicians we had known in our various previous positions began coming on board, and when I realized that many had put their eggs in this basket because of their confidence in me I scrambled particularly hard to create a positive work environment for them, with challenging patients, solid support and respect, and as few dissatisfiers as possible. In this information age there is little need to pull practicing clinicians away from their patients to drive for miles and sit in meetings. "On call" can be managed safely and with minimal imposition. Efforts above and beyond the usual can be recognized and rewarded, and the need for sleep, family time, and simple down time honored and defended. We did all of this, and more.

After decades of working alongside them, my team and I knew some things about what physicians need and what presents problems for them. The same is true for hospital and extended care providers. So we solved some of those problems. We introduced people to clinicians with whom they had worked in the past and assured them that their commitment to being and doing the best had only increased, and had only more support. We had photographs of demonstrated results, and evidence from the literature explaining the scientific bases of our approaches.

And we had fun. The Rehab Specialist, who later became the Director of Rehabilitation Services, and I worked seven days a week . . . because we so chose, because we wouldn't let that patient in the hinterlands go without a nurse or therapist on the weekend, because we took care of our people, because we wanted to deliver a compelling presentation the next day or week or month or all of those, because new ideas and new possibilities had a way of popping into our heads in the wee hours of the morning . . . because we loved our work and knew we were making a positive difference in many, many lives.

That little agency went from being a virtual unknown to being one of the major players in the metropolitan area. We established affiliations with all of the university medical centers in the city and put liaisons on site at each one. And our liaisons were there to serve, not to sell. We focused on making things easier for referring providers and on securing the best possible clinical outcomes for patients. And our agency took off. We chuckled when from time to time we heard our competitors exclaiming the likes of, "What are they doing over there? That place is on fire!"

And it all happened because one day the owner had said to a part-time employee who hadn't even worked for him for the better part of a year, "I want you here in some capacity," allowed me to write my own ticket, and supported what followed, whether actively or simply by getting out of the way.

There's a lesson here.

Deepak Chopra says the best motivation is inspiration. What would happen if we began asking our people what they would like to do to earn their salaries? Truly, that's where it began for me. I needed to go from "in some capacity" to defining what that capacity would be, with an eye to professional satisfaction for myself, to serving in a way that mattered, and to adding sufficient value to my employer to justify my salary.

If instead of writing detailed job descriptions including pages of required qualifications, tasks, and "other duties as assigned" and then forcing people into those roles, what would happen if more people had more opportunities to offer service as they uniquely could, and we watched and we cheered and, when requested or needed, we helped? What would happen if even in an endeavor as serious as healthcare people were free to be a little crazy, and we encouraged rather than stifled that?

WE'D LOSE MONEY! I can hear it now.

But I don't think so. Highly educated, licensed clinicians who have demonstrated skillful execution of their professions for years and who have managed even basic household budgets can be trusted to carry our their work responsibly, including fiscally responsibly. And with freedom to practice and a modicum of sense, there's no need to game the system or manipulate. Imagine the energy that this alone can free up!

Let me tell you about "Camella."

Camella lived with her daughter in a high-rise in Chicago's Cabrini-Green public housing development, and truth be told I don't remember exactly what problem precipitated her hospital stay and subsequent referral to home healthcare. But I do remember the first day I walked into that home. After the usual climb up several flights of dark, smelly stairs, having passed the cadre of drug dealers out front, I entered Camella's apartment and stuck to the floor. Yep, every step I took turned the bottoms of my shoes into suction cups; the floor was that dirty, that sticky. There were flies and probably rodents, and definitely no safe places to set my bag or coat. I piled anything I didn't immediately need onto my police escort, who stood stiffly in the middle of the floor, "stuck" himself and surely not wanting to move too close to any furniture or walls.

Camella was lying on a sagging, urine-soaked mattress, curled tightly in a fetal position, and frail as she appeared, able to let out an ear-splitting cry of "AAAAAAAAA," with the "A" sounding like the "a" in "cat," when anyone so much as approached, much less attempted to touch or move her. She was blind and utterly immobile in that bed, and I quickly discovered that her arms and legs were "frozen" in their curled position. The connective tissue that links muscles and bones and holds them together shortens and becomes very stiff if a person doesn't move, and after awhile it won't move at all, causing joints to become contracted, immobile. This is what had happened to Camella. And when despite her "AAAAAAAA" I moved her enough to examine her I found eighteen pressure ulcers, also known as bedsores, on her body. Some were large and deep enough to encompass my entire hand; some were small and crusted with God-knows-what under those hard and dark covers, and others were at various points in between. In over forty years of practice I never before and never since saw eighteen pressure ulcers on one body at one time. But Camella had them.

On the verge of reporting her daughter to adult protective services for elder abuse, I asked in, the most measured and professional way I could muster, some version of the question, "What the !$%#÷¿%@! have you been doing?!"

And she told me. In a word, her answer came down to, "Trying." And gradually understanding the larger scenario, I couldn't fault that.

There was no place other than that urine-soaked mattress for Camella to sleep. "Jane," her daughter, didn't have enough sheets to change the linens every time Camella urinated, and because the mattress was so wet clean sheets didn't make much difference anyway. Camella couldn't move and wouldn't try, so there was no place to put her even temporarily. Any time Jane attempted to move her, even to change wet clothing, Camella let out that ear-splitting "AAAAAAAAA," so both not wanting to hear that and fearing she somehow was hurting her mother, as much as possible Jane left her alone. Jane had small children in her care as well as her mother, and both her good heart and her frayed nerves clearly were visible.

I put my hackles back down and set to work.

A hospital bed was delivered that day, and diapers and disposable underpads ordered. Steeling myself against the "AAAAAAAAs," I cleaned, measured, and dressed Camella's wounds. I began teaching Jane how to care for them, as well as about Camella's need for good nutrition and to be turned and repositioned frequently, regardless of the sounds such efforts generated. Once clean and repositioned Camella magically was still . . . and content. She admitted that she felt much better, and acknowledged understanding that we needed to continue to do what I just had done.

For reasons I don't understand, the Physical and Occupational Therapists I sent into that home still talk to me today, and boy do they have stories! Shortening the tale, I'll say that Camella learned to sit up and feed herself. We ordered a bedside commode for her, and she learned to move from the bed to the commode by herself, at which point we discovered that she hadn't been uncontrollably incontinent of urine and feces but rather simply had been unable to get to a location where she could eliminate properly. Jane mopped the floor and we stopped sticking to it, and as she cleaned more and more I even came to be able to set down my belongings. The greatest achievement of all, though, was when Camella started walking, after weeks and weeks of screaming "AAAAAAAA" at the therapist from the moment he hit the apartment door through careful efforts to loosen and straighten those contracted extremities, to building enough strength that Camella could bear her own weight. Oh, her posture was bent and she needed help, but indeed, she walked! Eventually she decided that walking was more trouble than it was worth. Being blind she couldn't see where she was going and felt vulnerable, so she opted to stay in her wheelchair, which she learned to wheel around the apartment herself.

It took months, but those eighteen pressure ulcers healed. They were quite a project, as there was no way Camella could sit or lie that her body's weight wasn't on at least some of them, and because the various ulcers were of different sizes, depth, and tissue types, and they had different amounts of drainage, I needed a variety of dressings and bandages to manage them. Day after day after day I made my way past the gangbangers dealing drugs, up the dark and smelly stairs, and into that apartment to tend those wounds, teach Jane how to change bandages when I wasn't there, and manage Camella's care overall. Eventually she healed.

As our time together was coming to an end Christmas also was approaching. Rarely at a loss for words I was struck dumb when Jane presented me with a gift: A beautiful "angel" doll bearing a banner that read, "Peace on Earth." Jane had barely two nickels to rub together, but she had seen that doll in a catalog and knew it was for me. She said that she learned later that there was a "nurse" doll as well and had she known she would have chosen that one. If only I'd had the words to tell her that there is no greater possible honor than being perceived an angel of peace, particularly for someone who looks like me working in a setting that. "Nurse" pales in comparison . . . and in my book "nurse" doesn't pale in the face of much!

Here's the reason for this story: Somewhere along the line my manager said, not unkindly and not telling me to stop what I was doing, "I want to show you something. I know you're saving her life, but look how much money we're losing on this patient!" She handed me pages of the statement from Camella's account.

Medicare reimburses home healthcare by allocating a sum of money to cover up to sixty days of service. There is a lengthy assessment form that the clinician, usually a nurse, admitting a patient to home healthcare must complete, and this determines how much the agency will be paid for serving that patient for the two month period. Diagnoses are considered, of course, with some carrying higher reimbursement than others. Other considerations include how much patients can do for themselves and how much they need help, whether they are blind, short of breath, incontinent, or have ostomies or infusions, and whether they can manage their medications. There are many variables, and once assessed all combined result in a specific payment to the home healthcare agency.

Camella did not have an ostomy or an infusion; beyond that I can't think of many "payment variables" that she didn't have. But I had a sinking feeling that the numbers on that financial statement I was about to review wouldn't be pretty, because there is nothing on the assessment form that takes into consideration the presence of eighteen ulcers that need to be treated. In fact, the form asks if the patient has one ulcer, two, three, or four or more, implying that the money pot is the same for four ulcers as it would be for seven or twelve . . . or eighteen. I couldn't fault the feds, or any of the researchers who did the background work to develop this tool. Who on earth would anticipate that a human being needing care at home would have eighteen pressure ulcers?

So I looked at the first page of that financial statement and saw a nice amount of money that the agency indeed had received for Camella's care. But then I saw all my visits, and all the therapists' visits, all the supplies we had ordered, and all the time that had gone by. Page after page, I looked. And indeed, ultimately the number at the bottom of the "expense" column was far greater than the one at the bottom of the "revenue" column.

But then I looked more closely. The assessment form that determines payment to the agency must be completed every sixty days, and every sixty days a new payment amount is generated. The financial statement in my hands noted only the revenue for the first sixty day period, but expenses were listed for six or eight months. There should have been three to four times the amount of revenue stated, but nothing after the initial payment was noted. This was a working document and not an official record; my guess would be that it was generated for analysis of the very substantial expenses Camella's care had required rather than to evaluate profit vs loss.

I did some quick math. Camella stopped being incontinent and needed less help bathing and dressing, but she still needed some help with everything, she still was blind, and she still had a lot of wounds, not eighteen over time, but always "four or more." The payments to the home healthcare agency following the first sixty day period still would have been substantial, and as Jane learned to change bandages and manage her mother's care the therapists and I visited less frequently. So while revenue may have decreased somewhat, expenses did even more.

On the basis of my quick calculations it was apparent that even with this patient's extreme needs, the home healthcare agency had turned a modest but significant profit. This was possible because the therapists and I managed her care well. We did not make unnecessary visits, we taught her daughter how to care for her, and we ordered only what was needed.

In life one does well by doing good. In business, and in healthcare, that's true, too. If an agency doesn't lose money on the likes of a patient such as Camella, then there aren't too many risks than an inspired clinician might take that would materially jeopardize the financial position of the company. This doesn't give license to being foolish or to failing to think through an idea and its potential consequences, but it does mean that there's room to be a little unconventional, to break out of old molds, to release some control, and to have faith in one's staff, managing from that faith rather than from fear.

There is room for fraud and abuse in the system, and, sadly, those happen every day. But Camella taught me that doing the right thing pays off: After I had picked my way through the dirt and the dangers, providing the needed services, teaching and supporting the family, and trusting enough to ease off and eventually go away when the job is done, the home healthcare agency made money, and I somehow had to reconcile my imperfect self with an image of an angel of peace in a time and a place where peace perhaps was needed most of all.

Coupling the experience with such patients as Camella with later being given the chance to write my own ticket and report to a business owner who didn't even know where I was or what I was doing most of the time but trusted me anyway and had my back, and seeing astoundingly positive outcomes of both types of endeavors I am more convinced every day that we don't need to live in a world where those who serve say, perhaps daring to do so only to themselves, "I love my work but hate my job." Even with seemingly hopeless clinical cases and with seemingly stifling regulatory red tape, health can happen: Healthy patients, healthy organizations, healthy, satisfied, and productive workers.

What would happen if we stopped scheming, cheating, manipulating, and justifying, and instead put one foot in front of the other and took the next right step, and the next one, and the one after that? If we managed patients rightly and well, and if in our organizations we set our people free, delighted in their flight, and assured them a soft landing? What if we stopped being afraid to take risks, whether this meant no longer gaming the system for more money for oneself or one's business, or trusting one another to define what working "in some capacity" best could be for them? What would happen if instead of directing and controlling we asked and listened? What would happen if workers didn't need to do an end run around their employing organizations in order to survive, feel safe, and thrive? What would happen if workers could try out their ideas instead of having them referred to committees, councils, and layers of administrative bureaucracy guaranteed to suck every drop of creativity and life out of them? What would happen if we stopped focusing on "marketing" and started focusing on developing extraordinary products and services? In short, what would happen if we all discovered the reality of

Doing Well By Doing Good?