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September 2019 • Vol.10 No.5

Incontinence care under a new payment system PDPM may bring about some subtle changes in care management.

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CONTENTS »» SEPTEMBER 2019 2 Wounded soldiers aren’t forgotten After 25 years serving medical customers and sales teammates, Gary Corless continues his service … to wounded soldiers

8 Wearables and the Supply Chain How does the healthcare supply chain fit into a world of wearable, digital devices?

12 Incontinence care under a new payment system PDPM may bring about some subtle changes in care management.

22 Setting Them Up For Success A bad system will beat a good person every time

24 Health news and notes

The Journal of Healthcare Contracting is published bi-monthly by Share Moving Media 1735 N. Brown Rd. Ste. 140 Lawrenceville, GA 30043-8153 Phone: 770/263-5262 FAX: 770/236-8023 e-mail:

PUBLISHER John Pritchard


Lizette Anthonijs

EDITOR Mark Thill

ART DIRECTOR Brent Cashman

Julie Seidel




The Journal of Healthcare Contracting (ISSN 1548-4165) is published bi-monthly by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2019 by Share Moving Media All rights reserved. Please note: The acceptance of advertising or products mentioned by contributing authors does not constitute endorsement by the publisher. Publisher cannot accept responsibility for the correctness of an opinion expressed by contributing authors.

The Journal of Healthcare Contracting | September 2019



Carry Forward is a 5K event that asks participants to show their support for warriors by carrying a flag, a weight or another person.

Wounded soldiers aren’t forgotten After 25 years serving medical customers and sales teammates, Gary Corless continues his service … to wounded soldiers

“Everything that we build professionally and personally, we build on a foundation of safety and security that we largely take for granted. That foundation doesn’t just exist. It must be fought for … and lives are lost for it and forever changed for it. “I had been grateful to those who served and sacrificed, but I had been mostly passively grateful. I needed to step up and put my beliefs into action.” Founded in 2003, Wounded Warrior Project helps serve the physical, emotional and financial needs of post-9/11

After serving customers, teammates and vendors for

warriors and their families, so they can

25 years in med/surg distribution – including serving as CEO

achieve their highest ambitions. It does

of PSS (now McKesson Medical-Surgical) and COO of McKesson

so through a variety of programs, and

Medical-Surgical – Gary Corless decided to step up and put his

also by supporting programs of other

beliefs into action. In April 2015, he became chief development

organizations with demonstrated abili-

officer of Wounded Warrior Project®.

ties to fill gaps and augment its existing

“Passive gratitude helps no one,” he says. 2

programs and services. September 2019 | The Journal of Healthcare Contracting

Last year, 33,067 warriors participated in the program. They join hundreds of thousands of retired and active-duty soldiers who have done so since 2003. More than 50 warriors and family members sign up every day. Corless’ team – Warrior Support – consists of development, public awareness and marketing. This includes fueling the mission as well as promoting and protecting the organization’s mission, vision, and purpose. WWP programs support mental and emotional wellness, familiarization with VA benefits, education, financial planning, life skills, physical health and wellness, and career assistance.

“Passive gratitude helps no one.”

finding civilian employment, healing the physical wounds, and dealing with the invisible wounds of war, such as traumatic brain injury and post-traumatic stress, says Corless. They may also struggle to establish a support system back home in

“It is rare that a day goes by when we don’t hear from a warrior or family member,” he says. “I can’t tell you how many times we hear, ‘It saved my marriage,’ or ‘It saved my life.’

their communities. But those who fought and became wounded since September 11, 2001, face some unique challenges. Advances in medicine are saving more lives on the battlefield, which in turn means more veterans are living with severe injuries

“Sometimes the wins are clearly vis-

for decades, he says. And some of those injuries – such as brain

ible,” he continues. “They may come in

injuries – may not fully exhibit themselves for years. “As a nation,

the form of someone being able to stand

we’re just learning about the impact of this type of warfare. The

up long enough to cook dinner or even

nature of these wounds is humbling, and it motivates us on a

speak after years of silence.” Or it could

day-to-day basis.”

be a warrior landing a job, getting a degree or moving into new housing.


What’s more, battlefield injuries often present new challenges for the veteran as he or she ages. For example, the physical and social needs of someone who has been amputated and fitted with a prosthesis often change over time. Wounded war-

Each generation of warriors faces similar

riors may need different medical equipment, different support

readjustment challenges in key areas, like

systems, and even different housing as they age.

The Journal of Healthcare Contracting | September 2019



Another issue unique to today’s soldiers is the fact that they come home to a country where relatively few others share their battlefield experience, says Corless. Ninety-nine percent of the population today did not serve in today’s all-volunteer force. Active duty personnel number 1.3 million, or less than 1% of all U.S. adults.

Med/surg training ground Twenty-five years in med/surg distribution served as a good training ground for Corless’ current work at WWP, because it helped him gain three skills: • How to lead by serving, that is, how to help others get what they need. • How to keep and share perspective, that is, how to stop running from task to task...deadline to deadline. Instead, taking time to see where and how we fit into the bigger picture. • How to get over oneself, that is, how to be a grateful, hard worker.

“I cherish the 25 years I had with my team,” he says. “For us it was always about each other. We wanted more for each other than we needed from each other.

“The nature of these wounds is humbling, and it motivates us on a day-to-day basis.”

I woke up every day knowing I had thousands of bosses. I still do … and I love it.” Those “bosses” are: • Warriors. “Making sure we truly understand the changing needs of the 160,000-plus injured veterans and family members we serve directly through our programs as well as the millions of post-9/11 veterans we represent through our advocacy.” • Team. “Making sure we have the best people, the right resources and a powerful culture.” • Supporters. “Reaching the right person with the right message at the right time, so that each American knows how he or she can make a very real and positive difference in the life of a wounded veteran.”


September 2019 | The Journal of Healthcare Contracting


A look at the post-9/11 warrior For the past 10 years, Wounded Warrior Project has conducted the largest, most statistically significant survey of this generation of wounded service members, says Gary Corless, chief development officer. “Over 30,000 warriors share their greatest challenges. Their needs guide our program investments and expectations.” The 2018 Wounded Warrior Project Annual Warrior Survey was the ninth annual administration of the survey. The web survey was fielded to 98,054 eligible WWP warriors from March 20 to May 14, 2018, and over 33,000 warriors completed the survey. Almost half of warriors (45.3%) deployed three or more times during their military career. Almost all warriors who deployed since 2001 did so at least once to a combat area (93.4%).

Key findings The four most common self-reported injuries and health problems among warriors include: • Post-traumatic stress disorder (PTSD) – 78.2% • Sleep problems – 75.4% • Back, neck, or shoulder problems – 73.7% • Depression – 70.3% • More than 60% of warriors are employed, and most (47.6%) are working full-time. The primary reasons warriors are not in the labor force include mental health injury (37.4%), physical injury (24.3%), retirement (15.6%), or current enrollment in school or in a training program (13.8%). • Almost one quarter of warriors (22.6%) currently work for the federal government. Slightly fewer warriors (15.6%) work in the military, including those on active

duty and those working in other military jobs. • Home ownership continues to increase. Among warriors, 59.6% of warriors own homes, with or without a mortgage balance. • About three in 10 warriors (32.4% in 2018) need the aid and attendance of another person because of their injuries and health problems. Among warriors needing assistance, approximately one-fourth (23.2%) need more than 40 hours of aid every week. • More than eight in 10 warriors (85.8%) said maintaining their health is either very important or moderately important, and 42.1 percent of warriors do moderateintensity physical activity or exercise three or more days a week. • Similar to 2017, about half of warriors (49.1%) assessed their health as excellent, very good, or good, but half (50.9%) reported their health as fair or poor. • Over 80% of warriors report that they were less productive than they would have liked because of their physical health or emotional problems. More than eight in 10 warriors (83.9%) indicated that they were less productive than they would have liked because of emotional problems. • Female warriors are more likely than male warriors to say that

their financial status is worse than a year ago (29.7% of female vs. 25.6% of male warriors). This financial trend, along with the higher homelessness rate among female warriors, is a growing area of concern to many. • On a 10-item Social Provisions Scale, between 51.5% and 81.9% answered positively in 2018 to each statement about their current relationships with friends, family members, co-workers, community members, and others. (Example: “There are people I can depend on to help me if I really need it.”) • Past military experiences still adversely affect many warriors. More than three-quarters of warriors (77.2%) had an experience that was so frightening, horrible, or upsetting that they were constantly on guard, watchful, or easily startled. • Warriors understand that education is vital to improving their future opportunities. About one in four (23.2%) are now enrolled in school. • Maintaining a healthy weight continues to be a challenge for a large majority of warriors. The average body mass index (BMI) score for warriors is 30.8, slightly above the cut-off for obesity, which is 30.0. About half (51.7%) of warriors have BMI exceeding the obesity cut-off; 6.2 percent are morbidly obese. • Among warriors, 50.9 percent had visited a professional to get help with issues such as stress, emotional, alcohol, drug, or family problems in the prior three months, but access to care remains an issue.

Source: 2018 Wounded Warrior Project® Survey


September 2019 | The Journal of Healthcare Contracting

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Wearables and the Supply Chain How do med/surg distributors fit in a world of wearable, digital devices?

Investors, patients, payers and doctors are asking such questions. Med/surg distributors should probably do the same. “As part of a subscription-based service, we do not see the role of traditional distributors,” Nemaura Medical CEO Faz Chowdhury told The Journal of Healthcare Contracting in an email. Following is a look at three companies developing wearables, and their plans on

The names are new: AliveCor, Empatica, EnLiSense,

how to bring them to the U.S. market.

Nemaura, VivaQuant. The technologies are new: KardiaMobile, Embrace2, the SWEATSENSER and the sugarBEAT® continuous glucose monitor.

Nemaura Medical In July, Nemaura Medical (Loughborough, England) submitted a De Novo

And so are the questions being raised about wearables: • How accurate are they?

the U.S. Food and Drug Administra-

• Will they alter the way chronic disease is managed?

tion for its sugarBEAT non-invasive

• Who will pay for them – insurers, patients, providers?

continuous glucose monitor. Less than

• How will they pay for them – e.g., outright purchase, rental/

two months earlier, in May, the com-

lease, subscription? 8

510(k) medical device application to

pany had received CE Mark approval to September 2019 | The Journal of Healthcare Contracting

market and sell the device throughout

more recently with the use of a 14-day invasive sensor,” says

the European Union.

Chowdhury. “SugarBEAT can provide a superior level of service

SugarBEAT consists of a daily, dispos-

at a significantly reduced price (since sensors will only be used

able adhesive skin patch connected to

infrequently), therefore penetrating a far deeper patient pool.

a small rechargeable transmitter, con-

We believe for these reasons, sugarBeat is positioned for the

nected via Bluetooth to a mobile ap-

type 2 market.”

plication, which displays glucose read-

Questions remain as to how sugarBEAT will be marketed and

ings at five-minute intervals throughout

sold. Will it be available only by prescription? Will people with

the day. Passing a mild electric current

diabetes buy the device directly from the company? Will they

across the skin, sugarBEAT draws a small

rent them? If so, from whom?

amount of glucose molecules out of the

“Yet to be determined,” says Chowdhury. “But all of the

interstitial fluid, which sits just below

above are anticipated options, as part of subscription-based

the top layer of skin, into a chamber

services that offer much more than just the device.”

within the patch. The transmitter measures the glucose levels in the chamber,


then transmits the reading.

EnLiSense’s SWEATSENSER Dx platform uses passively

“We believe sugarBEAT is best posi-

expressed sweat to detect biomarkers related to vari-

tioned to conquer this market – of over

ous diseases, CEO Sriram Muthukumar told The Journal of

25 million diabetics in the U.S. – where

Healthcare Contracting in an email. “It can report levels in

we have a sensor that can be worn on

real-time and at low levels and therefore can be applied

intermittent days/periodic intervals, with

for pre-symptomatic situations. We have to date been able

a view to enhancing patient training/

to establish detection of biomarkers for diabetes, infec-

coaching to change lifestyle, diet, etc.,

tions, and immunological diseases.” EnLiSense is located

says Chowdhury, who holds a masters

in Allen, Texas.

degree in microsystems and nanotech-

“Since our platform is 100% non-invasive and diagnos-

nology, and a doctorate in nanomedicine

tic, we expect it to be a Class II FDA device that can be made

and drug delivery.

available OTC when we bring it to market,” said Muthukumar.

“In the UK the NHS is currently fund-

The company intends to sell it to patients and users through

ing ‘Apps’ with subscription-based servic-

healthcare providers, pharmacies and commercial channels,

es to help pre-diabetics avoid becoming

such as Amazon. The company would not share how it intends

diabetic and Type 2s to go into remission,

to price the device.

in order to save on the long-term socio-

In late 2018, EnLiSense was one of three companies to re-

economic costs,” he says. “We believe

ceive research and development funding from DRIVe, that is,

governments and healthcare providers

the Division of Research, Innovation and Ventures, which was

around the world will increasingly adopt

established by BARDA (the Biomedical Advanced Research

this stance.

and Development Authority), part of the Assistant Secretary

“We have already seen what Livongo is achieving with mainly coaching, and The Journal of Healthcare Contracting | September 2019

for Preparedness and Response within the U.S. Department of Health and Human Services. 9


(The other two companies receiving DRIVe funding were Petach Tikva, Israel-based Biobeat and San Francisco-based Spire.

potentially be used to alert users to impending illnesses before they strike.)

Biobeat’s wristwatch has been cleared by the FDA for monitoring blood pressure, heart rate, oxygen saturation, respiratory rate,


stroke volume, cardiac output, sweat, skin temperature and oth-

The Smart Pregnancy Tracker from San

er factors, under a technique known as reflective photoplethys-

Francisco-based Bloomlife is designed for

mography. Spire Health is a developer of the Spire Health Tag, a

simplified contraction tracking and is not

wearable device that monitors real-time bio-signals, like breath-

intended for diagnostic purposes, Eric Dy,

ing, heart rate, heart rate variability, activity and other changes

CEO and co-founder, told The Journal of

in the health signatures of the user’s health data. A companion

Healthcare Contracting in an email. “The

app sends notifications to the user’s cell phone that could

technology combines a discrete wearable patch with data analytics to provide moms with a convenient and accurate way to automatically track and time con-

For members only

tractions. This information provides reas-

Technology companies aim to tie patients and consumers tightly to them, disrupting conventional relationships. For example, in the world of subscription-based services, “patients” are considered “members” by companies such as Mountain View, California-based Livongo. The company develops technology to help people – members – manage hypertension, diabetes, weight management and behavioral health. “Livongo’s team of data scientists aggregate and interpret substantial amounts of health data and information to create actionable, personalized, and timely insights and nudges delivered to our members to help them stay healthier,” says the company on its website. In fact, when glucose readings are out of range, a Livongo “diabetes response specialist” may call or text the member to alert them to take action. “Our smartwatch integration allows us to capture information from our Members, add it to our AI+AI engine, and return actionable, personalized, and timely information back to them,” said Livongo President Jennifer Schneider, M.D., M.S., in a press release. “By offering another way to access personalized health insights, we are able to more easily influence positive behavior change, which we know can lead to better health.”

communicate with their care team, and

surance to moms, helps them more easily make more informed decisions toward the end of pregnancy.” The device is available for rental from the Bloomlife website for $20 a week. Bloomlife intends to submit an enhanced product – Bloomlife Plus – for FDA consideration later this year. Bloomlife Plus would identify labor onset. “Once the clinical and healthcare economic value is substantiated, medical distributors can help drive widespread adoption through their extensive networks and sales teams,” says Dy. “Bloomlife is bringing long overdue innovation to prenatal care, and we’re excited to find partners to help bring our vision to the market.”

Editor’s note: This is the first in a periodic series on wearables. Future articles will address such questions as: How is the FDA dealing with them? How are Medicare and other payers reimbursing physicians for remote monitoring of patients? Who will be buying and selling these devices and systems? What do The Journal of Healthcare Contracting readers need to know? 10

September 2019 | The Journal of Healthcare Contracting

Companies are coming hard and fast into the wearables arena. Here are a few of the more recent entrees. Company



AliveCor (Mountain View, California)

KardiaMobile 6L, six-lead personal ECG device. FDA clearance May 2019

Patient purchases bundle from AliveCor when setting up the Kardia app. (One-year connection.) Physician practice bills insurance every 30 days for remote patient monitoring.

Bloomlife (San Francisco, California)

Smart Pregnancy Tracker (launched in 2017) for contraction tracking. Company intends to submit an enhanced product, Bloomlife Plus, for regulatory approval in late 2019. Bloomlife Plus would detect early labor onset.

Smart Pregnancy Tracker is available by weekly subscription ($20). Bloomlife Plus has not been submitted to FDA yet.

Empatica, Cambridge, Massachusetts

Embrace2: FDA-cleared wristband detects patterns associated with tonic-clonic epileptic seizures in patients 6 years and over. Prescription necessary.

$249 plus subscription plan (starting at $9.90 per month and rising based on number of caregivers who receive alerts).

EnLiSense, Allen, Texas

SWEATSENSER Dx platform technologies: Uses sweat to detect early warning of changes to body’s physiological state (infection).

Not available

Nemaura Medical (Loughborough, England)

SugarBEAT® continuous glucose monitor; FDA De Novo application filed July 2019

Will be subscription-based. Company says daily price is expected to be comparable to cost of using glucose meters and strips.

Omron Healthcare (Lake Forest, Illinois)

HeartGuide™ wristwatch: Wearable oscillometric wrist blood pressure monitor. Cleared by FDA December 2018.

List price: $499. Complimentary access to HeartAdvisor, corresponding mobile app.

Verily (South San Francisco, California)

Study Watch: FDA cleared as Class II medical device (Jan 2019) for its on-demand ECG feature. Prescription only.

Not available

VivaLNK (Campbell, California)

Vital Scout: ECG monitoring device

Wellness monitor $149 (online). Four adhesives: $5.99.

VivaQuant (St. Paul, Minnesota)

RX-1 identifies and reports cardiac arrhythmias. FDA clearance April 2019.

Not available

The Journal of Healthcare Contracting | September 2019



September 2019 | The Journal of Healthcare Contracting

Incontinence care under a new payment system PDPM may bring about some subtle changes in care management.

Medicare’s new payment system for post-acute-care facilities – the Patient Driven Payment Model, or PDPM – will bring changes to SNFs’ accounting and coding departments. It will also encourage SNFs to take a more individualized approach to the care of each resident, and it will reward them for doing so. “PDPM is a reimbursement change, not a clinical

the number of hours they spend providing physical

change, for our facilities,” says Nate Ovenden, RAC-

therapy, occupational therapy or speech/language

CT, senior Medicare & managed care consultant,

pathology therapy. Under PDPM, more therapy

Good Samaritan Society, Sioux Falls, South Dakota.

hours won’t add up to more reimbursement dollars.

“I don’t see it directly impacting any incontinence is-

(That said, the level of therapy anticipated for each

sues we see in our buildings. What is medically nec-

resident will continue to be one factor in the new

essary in RUGS IV is still medically necessary under

reimbursement scheme.)

PDPM. That is something CMS has been very clear about, and they will monitor drastic changes in be-

Under PDPM, residents will be classified into one

havior from RUGS-IV to PDPM.

group for each of five case-mix-adjusted components:

“Our facilities have been trained to do the right

• Physical therapy (PT).

thing at the right time for the right person,” he con-

• Occupational therapy (OT).

tinues. “The only difference is that PDPM will help

• Speech/language pathology (SLP).

offset the costs of doing so a little more than RUGS-

• Nontherapy ancillary services (NTA).

IV. So there is a bit of light at the end of the tunnel for

• Nursing.

facilities that have been doing the right thing.” For each of the components, there are a number

Winners and losers

of groups to which a resident may be assigned, based

Effective Oct. 1, PDPM is designed to be budget-

on the relevant MDS 3.0 (assessment) data. There

neutral. But there will be winners and losers.

are 16 PT groups, 16 OT groups, 12 SLP (speech/lan-

The winners? Skilled nursing facilities that accu-

guage pathology) groups, six NTA groups, and 25

rately assess the needs of the resident upon admis-

nursing groups. PDPM classifies residents into a sep-

sion, and provide care accordingly.

arate group for each of the components, which have

The losers? Facilities that cling to the old reimburse-

their own associated case-mix indexes and per diem

ment method, which rewards SNFs that maximize

rates. Additionally, PDPM applies per diem payment

The Journal of Healthcare Contracting | September 2019



adjustments to three components, – PT, OT, and NTA

“Depending on how many of these are present

– to account for changes in resource use over a stay.

and other conditions and treatments identified on

The adjusted are then added together (with the un-

the MDS, these incontinence-related MDS items

adjusted SLP and nursing component rates and the

may impact PDPM rates from roughly $20 to $50 per

non-case-mix component) to determine the full per

day,” he says.

diem rate for a given resident.

Dollar impact

In the nursing component, MDS items H0200C and H0500 – denoting urinary and bowel toileting training programs, respectively – are used as case-

PDPM’s impact on incontinence care will depend

mix rate adjustors for eight of the 25 PDPM nursing

not only on the component case-mix payment rates,

component groups. They may impact PDPM rates

including Minimum Data Set (MDS) resident assess-

from roughly $5 to $25 per day if associated restor-

ment items that are clearly incontinence-related,

ative nursing services are also furnished, says Ciolek.

says Dan Ciolek, associate vice president, therapy

Incontinence issues often are directly associated

advocacy, American Health Care Association. “It also

with infections, skin conditions (including decubitus

depends on other MDS items that can be influenced

ulcers), functional impairment, falls, and cognitive

by or are side effects of incontinence issues.”

impairment associated with disturbed sleep patterns, he continues. These fac-

Instead of the traditional ‘onesize-fits-most-everyone’ approach, long-term-care providers will have to be thoughtful about what ‘stock’ they carry, versus what ‘individualized items’ they carry.

tors can significantly impact the PDPM case-mix groups for the NTA and nursing components, as well as impact the physical therapy, occupational therapy, and speech-language pathology PDPM components. (The Journal of Healthcare Contracting readers should note that for the first three days of the stay, providers will receive 300

For example, the non-therapy ancillary (NTA)

percent of the calculated NTA payment compo-

component assigns points to specific services and

nent, to account for the typically heavy investment

conditions associated with higher NTA costs, Ci-

in med/surg supplies, drugs. etc., at the beginning

olek explains. Three incontinence-related MDS

of a resident’s stay. Starting on Day 4, this will drop

items (H0100C – Appliances: Ostomy; H0100D –

to 100 percent.)

Appliances: Intermittent Catherization; and I1300


Ulcerative Colitis, Crohn’s Disease, or Inflamma-

Subtle changes

tory Bowel Disease) are each assigned one NTA

PDPM may bring about some subtle changes. Be-

component point.

cause PDPM is meant to be more patient-centered, September 2019 | The Journal of Healthcare Contracting

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Incontinence: Not necessarily a forever thing Incontinence impacts many short- and long-stay residents in a nursing facility, says Dan Ciolek, associate vice president, therapy advocacy, at the American Health Care Association. “Not only are there numerous physicalhealth-related consequences, but residents can also be psychologically impacted by a loss of dignity and could become susceptible to social isolation and depression.” PDPM’s emphasis on individualized care, along with new quality standards, may help. Many forms of incontinence are preventable, and some can be reversed with focused interdisciplinary approaches, says Ciolek. The implementation of PDPM will align payments with the SNF Requirements of Participation (RoP) and Quality Reporting Program (QRP), he points out. “This creates opportunities for providers to explore and develop innovative solutions to reduce the costs of care while maintaining or improving quality. I believe that over the next few years, providers will be exploring ways to prevent and treat incontinence using evidence and best practices. “I have seen examples where SNFs have developed incontinence risk assessments, monitored the prevalence of incontinence, monitored call light patterns, conducted staff time studies, evaluated falls with and without injuries, noted prevalence of urinary tract infections and hospitalizations, identified associated skin disorders, tracked functional independence, and evaluated resident, family and staff satisfaction and laundry and supply costs associated with residents at-risk for or who are currently incontinent,” he continues. “From these analyses, they changed practices and interventions to be more evidence-based and residentcentered. For example, in states whose laws permit it, SNFs are identifying residents that are clinically appropriate for the delivery of Percutaneous Tibial Neuromodulation (PTNM) within the scope of practice of physical therapist services for certain types of urinary incontinence. They are experiencing notable improvements in the quality of care and resident and employee satisfaction, while reducing overall costs.”

nursing must ensure that caregivers accurately and fully describe the impact of the patient’s continence status, as that will be associated with the cost of pullons, incontinence pads or adult briefs,” says Dea J. Kent DNP, RN, NP-C, CWOCN, president-elect, Wound, Ostomy and Continence Nurses Society™ (WOCN®). “Incontinence, whether bowel or urinary, is a valid diagnosis that requires a medical supply,” she continues. “Currently, incontinence supplies in some facilities may be accounted for, or may be billed, to the patient. It will be interesting to see how this model operates upon implementation. Some components of incontinence care go unaccounted for, such as preventative creams, which ensure that skin health is maintained in areas that incontinence may affect. No single category in the current or future payment model accounts for those costs.”

“Providers are going to become more sensitive to the balance between the overall costs of the incontinence-related products/ devices/equipment, and their effectiveness.” Instead of the traditional “one-size-fits-mosteveryone” approach, long-term-care providers will have to be thoughtful about what stock they carry, versus what individualized items they carry, she says. “I hope that gone will be the days that because there is only one size of adult brief available, everyone who is incontinent will have that size placed on,” she says. “That is not the most dignified approach, it is not evidence-based, and it certainly does not support


September 2019 | The Journal of Healthcare Contracting










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the Triple Aim,” that is, improving the patient experi-

Lake Elmo, Minnesota. For example, the old inconti-

ence of care, improving the health of populations,

nence brief may be OK for more dependent people,

and reducing the per capita cost of healthcare. “In

but there are many products designed for younger

fact these practices actually lead to more urinary de-

and more independent residents in the future, she

pendency,” she says.

says. It is essential to assess residents for the type of

“I also hope that it becomes standard practice to

incontinence and to plan an appropriate program.

thoughtfully promote continence behaviors, even in

Because restorative nursing calls for providers to

the memory-impaired patient. Toileting is cheaper than

help residents achieve their highest level of func-

placing a brief, and is less cumbersome on the staff. A

tioning, it’s no surprise that things that aid mobility – e.g., canes and walkers – will be

The old incontinence brief may be OK for more dependent people, but there are many products designed for younger and more independent residents in the future.

on their shopping list as well, just as adaptive equipment for eating has proven effective for some patients who were unable to feed themselves, she adds. For suppliers, “the theme of the day is ‘value,’” says Ciolek. “Providers are going to become more sensitive to the balance between the overall costs of the

focus on prevention of moisture-associated skin dam-

incontinence-related products/devices/equipment,

age may also mean less pressure injury/ulcer develop-

and their effectiveness. Once a person becomes in-

ment, since the skin health in those moist areas may

continent, the costs of care and risks for additional

have a hyperfocus instead of being an afterthought.

negative health consequences increase markedly,

“Lastly, more continence awareness may lead to

so savvy providers will most likely be seeking solu-

better assessment, and better and more appropriate

tions that would be effective at helping prevent or

intervention, which ultimately will make less work

reverse incontinence.

for caregivers, allowing them to spend more quality time with their patients.”

“For residents whose incontinence is unlikely to be reversible, knowledgeable providers will be

The need for facilities to help residents with blad-

seeking solutions to reduce the risk for secondary

der or bowel issues for quality and to maintain dig-

health and psychological complications as well as

nity will affect the products they select, says Susan

avoid or minimize increases in direct staff care time


needed to use the incontinence-related products/

IP-BC, director of education for Pathway Health in


Editor’s note: The Wound, Ostomy Continence Nurses Society has an online algorithm to assist caregivers with incontinence product implementation. It can be found at 18

September 2019 | The Journal of Healthcare Contracting

Non-acute product and service standardization can be painful . The possibilities of managing disparate care sites are endless. But so are the complexities when it comes to navigating, coordinating and communicating around contract compliance, reimbursement trends, cost avoidance/restructuring, and operational efficiency.

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The ‘highest level of functioning’ Restorative nursing for incontinent residents The concept of “restorative nursing” will play a strong role in incontinence care at post-acute-care facilities under PDPM, as it has under RUGS-IV, says Susan LaGrange, RN, BSN, NHA, CDONA, FACDONA, CIMT, IP-BC, director of education for Pathway Health in Lake Elmo, Minnesota. The concept has existed for years, says LaGrange, who teaches restorative nursing around the country. It’s a formal program based on resident assessment that works on specific restorative programs, for example, passive range of motion, active range, splint or brace, bed mobility, walking, transfer, dressing, grooming, eating and swallowing, amputation or prostheses care, communication and toileting, she says. “The whole idea is to keep residents at their highest level of functioning,” she says. What’s more, particularly for toileting, it’s a matter of maintaining residents’ dignity. Evaluating a resident’s need for incontinence care calls for an interdisciplinary team approach. Not only does the facility have to consider the resident’s toileting patterns, but other components that might be relevant, such as the person’s cognitive abilities, diagnosis, medications, and ability to get up and go to the toilet. The team also must identify the type of incontinence they’re dealing with. Someone with stress incontinence – that is, a resident who experiences small to moderate leakage when laughing or coughing – will have different needs than someone who is incontinent because they can’t get out of their chair or bed in time to get to the toilet.


When attempting to determine the type of incontinence, bladder scanners are a much less invasive way than catheters to identify how much urine the resident is retaining post void, she says. “Depending on all these different types – the care plan will be different,” says LaGrange, In the past several years, facilities have begun to focus on fecal incontinence as well as urinary, she adds.

Begin at the beginning Traditionally, restorative nursing has often commenced only after formal therapy was completed in the long-term-care setting, points out Dea J. Kent DNP, RN, NP-C, CWOCN, president-elect, Wound, Ostomy and Continence Nurses Society™ (WOCN®). But under PDPM, facilities would be well-advised to evaluate residents and coordinate restorative nursing with therapy at the beginning of

“The demand for restorative nurse aides to assist with bowel and bladder programs to promote continence must have a serious renaissance.”

the stay. If they fail to indentify the need for restorative therapy upon admission, they won’t be able to capture reimbursement for it unless they undergo an interim payment assessment, or IPA. “In order to achieve the most success with patient care and the changing payment model, I believe the savvy director of nursing will partner with both the staff educator and a continence expert, such as a Certified Wound Ostomy Continence Nurse from the community at large, to provide education, empowerment and validation for licensed and non-licensed nursing staff alike regarding incontinence etiology, treatment, containment, recognition and prevention. “It will be important to recognize not just the type of incontinence from a medical pathology standpoint, but to also recognize the level of incontinence. The level of incontinence and type, in combination with mobility status, can be utilized to implement evidencebased best practice for appropriate product utilization as well as sound skin breakdown prevention strategies. “This up-front education and validation will definitely allow the staff to provide timely, accurate and effective management of incontinence, which should not only contain and streamline costs, but likely promote an increase of quality of care, while maintaining and even boosting the self-image of the patients who are living with incontinence of all types. “Additionally, bowel and bladder programs have been mandated for years, and at this point, the importance of restorative nursing care will exponentially increase.,” she says. “The demand for restorative nurse aides to assist with bowel and bladder programs to promote continence must have a serious renaissance.”

September 2019 | The Journal of Healthcare Contracting

A safer healthcare experience by design Being a healthcare provider is demanding. And it’s not just lifting patients that puts today’s caregivers at risk—increased time behind a computer is likely to add to the already high rate of injuries.

Midmark Workstations are designed to support the height requirements for 95% of users in the clinical setting. That’s better ergonomics for every body. Learn more at: © 2019 Midmark Corporation, Miamisburg, Ohio USA


By Lisa Earle McLeod

Setting Them Up For Success A bad system will beat a good person every time

Paying the price for systemic failures Let’s go back to our waitress. The food was late because the kitchen was short staffed that day. Our server had noted salad dressing on the side in the order system. But the salad was mixed before they got to the expo station. The

The waitress was late with the food. She looked fraz-

food runner saw dressing on the side,

zled and frustrated. After she rushed off, we discovered the sal-

so he added another container of ranch

ad we requested with dressing on the side was doused in ranch.

to our plate. As for being frazzled,

Clearly, she wasn’t a good server. Or was she?

wouldn’t you be if half your orders were

Edwards Deming said, “A bad system will beat a good person

late, and customers were complaining

every time.” I’ll take it step further, a bad system will chip away at your soul. Bad systems can turn even the most enthusiastic workers into frustrated poor performers. 22

about dressing? If you’ve ever waited tables, you’ve no doubt experienced this for yourself. September 2019 | The Journal of Healthcare Contracting

The front line often pays the price for

One woman put post its across her wall, another kept his client

systemic failures.

to do’s on a yellow pad. There was no systemic way for people to

As you look at your own organiza-

log notes, and have them pop back up until they were handled.

tion, be it your workplace or your home,

It’s easy to say people should create their own systems, but

ask yourself, are your systems set up to help people be their best, or do they create obstacles? As a consultant, I frequently see organizations try to solve problems by

individual systems can’t scale. One of my friends used to keep a birthday daybook. She was great about sending everyone a nice note on their special day. In terms of birthdays, she was a top performer. I always felt guilty not being that kind of friend.

training employees or trying to get better employees. In many case the issue is the system. Recently, we were working with an organization where customer callbacks were a problem. A few employees were great at calling clients backs. But, more often than not, when customers called in with problems, the employees would promise to look into it, and fail to call back. Further investigation revealed that employees were making notes with the intent of getting back to customers. Yet as the day wore on, and the tasks piled up, they never circled

As you look at your own organization, be it your workplace or your home, ask yourself, are your systems set up to help people be their best, or do they create obstacles?

back. After it sat for a few days, the employees either forgot about it, or were too embarrassed to call back. The leadership team assumed it was a training and accountability issue. If the

Now, thanks to Facebook reminders, my good intentions can scale. Mediocre me is now a top performer in the birthday category.

top performers could do it, clearly some-

If you want your team to excel at scale, look at your sys-

thing must be wrong with everyone else.

tems. Whether it’s dressing on the side, scheduling patient ap-

After watching the team for an after-

pointments, or how you handle inventory, ask yourself, is my

noon, I saw the problem. The top performers had created workarounds to ensure they never lost track of client issues.

system setting my team up for success? A bad system will beat a good person. A great system will help all the good people be great.

Lisa Earle McLeod is a sought after keynote speaker who has rocked the house everywhere from Apple to Peterbilt Trucking. McLeod is known for her cutting edge ideas, practical techniques, and inspirational humor. She is the author of 4 bestselling books, in 4 genres: leadership, sales, personal development and a collection of humor essays. For more information, visit

The Journal of Healthcare Contracting | September 2019



Health news and notes Important tip for patients Patients whose surgeons had higher numbers of coworker re-

Risks associated with vinpocetine

ports about unprofessional behavior in the 36 months before

The dietary supplement vinpocetine

the patient’s operation ap-

may cause a miscarriage or harm fetal

peared to be at increased

development, warns the U.S. Food and

risk of surgical and medical

Drug Administration. These findings are

complications, according to

particularly concerning, since products

a study in JAMA Network. The

containing vinpocetine are widely avail-

researchers concluded that

able for use by women of childbearing

surgeons who model unpro-

age. Vinpocetine is a synthetically pro-

fessional behaviors may help

duced compound that is used in some

to undermine a culture of

products marketed as dietary supple-

safety, threaten teamwork,

ments, either by itself or combined

and thereby increase risk for

with other ingredients. Vinpocetine

medical errors and surgical

may be referred to on product labels as

complications. The findings

Vinca minor extract, lesser periwinkle

suggest that organizations interested in ensuring optimal pa-

extract, or common periwinkle extract.

tient outcomes should focus on addressing surgeons whose

Dietary supplements containing vin-

behavior toward other medical professionals may increase pa-

pocetine are often marketed for uses

tients’ risk for adverse outcomes.

that include enhanced memory, focus,

From gloom to gratitude

or mental acuity; increased energy; and weight loss.

A positive outlook can lead to less anxiety and stress, according


to a new study of caregivers, as reported by NPR. Here are eight

Sleep regularly

skills to help cope with stress: 1) identify one positive event

Failure to stick to a regular bedtime and

each day; 2) tell someone about that positive event; 3) start

wakeup schedule – and getting differ-

a daily gratitude journal, identifying even the little things for

ent amounts of sleep each night – can

which you’re grateful; 4) identify a personal strength and note

put a person at higher risk for obesity,

how you’ve exercised it recently; 5) set a daily goal and track

high cholesterol, hypertension, high

your progress; 6) practice “positive reappraisal,” which means

blood sugar and other metabolic disor-

reframing unpleasant events in a more positive light (e.g., turn

ders, according to a study funded by the

stop-and-go traffic into a moment to savor the stillness); 7) do

National Institutes of Health and pub-

something nice for someone every day; 8) pay attention to the

lished in Diabetes Care. In fact, for every

present moment (try a 10-minute breathing exercise).

hour of variability in time to bed and September 2019 | The Journal of Healthcare Contracting



770-263-5266 e-mail:


time asleep, a person may have up to a 27% greater chance of

play a role in a variety of common hu-

experiencing a metabolic abnormality. “Many previous studies

man cancers. In a paper published in

have shown the link between insufficient sleep and higher risk

Science, researchers, led by Pier Paolo

of obesity, diabetes, and other metabolic disorders,” said study

Pandolfi, M.D., PhD, director of the Can-

author Tianyi Huang, Sc.D., epidemiologist of the Channing

cer Center and Cancer Research Insti-

Division of Network Medicine at Brigham and Women’s Hos-

tute at Beth Israel Deaconess Medical

pital, Boston. “But we didn’t know much about the impact of

Center, demonstrated that targeting the

irregular sleep, high day-to-day variability in sleep duration

gene, known as WWP1, with the ingredi-

and timing. Our research shows that, even after considering

ent found in broccoli suppressed tumor

the amount of sleep a person gets and other lifestyle fac-

growth in cancer-prone lab animals.

tors, every one-hour night-to-night difference in the time to bed or the duration of a night’s sleep multiplies the adverse metabolic effect.”

Vitamin D supplement won’t prevent type 2 diabetes

A single injection of antibiotics significantly reduces the risk of infections

Taking a daily vitamin D supplement does not prevent type 2

when women who are giving birth re-

diabetes in adults at high risk, according to results of a study

quire the aid of forceps or vacuum ex-

funded by National Institute of Diabetes and Digestive and

traction, a study published in Lancet

Kidney Diseases (NIDDK), part of the National Institutes of

concludes. The routine use of the pro-

Health. “Observational studies have reported an association

phylactic shot actually reduces antibiot-

between low levels of vitamin D and increased risk for type

ic use in the long run, the study found.

2 diabetes,” said Myrlene Staten, M.D., D2d project scientist

British researchers randomly assigned

at NIDDK. “Additionally, smaller studies found that vitamin D

3,420 women who had operative vagi-

could improve the function of beta cells, which produce insu-

nal births to one of two groups: The first

lin. However, whether vitamin D supplementation may help

received a single shot of Augmentin

prevent or delay type 2 diabetes was not known.” The study

(amoxicillin and clavulanic acid) within

enrolled 2,423 adults at 22 sites across the United States, and

six hours of giving birth, and the second

results were published in the New England Journal of Medicine

a placebo saline shot. Then they tracked

and presented at the 79th Scientific Sessions of the American

infections over the next six weeks. Com-

Diabetes Association in San Francisco.

pared with the placebo group, women

Eat your broccoli


Antibiotic shot may prevent childbirthrelated infections

who got the antibiotic had a 42 percent reduced risk for any infection, and a 56

Your mother was right; broccoli is good for you. Long associ-

percent lower risk of a bodywide infec-

ated with decreased risk of cancer, broccoli and other cru-

tion. Antibiotic users had about half the

ciferous vegetables – the family of plants that also includes

risk of perineal wound infection com-

cauliflower, cabbage, collard greens, Brussels sprouts and

pared with the placebo group, and they

kale – contain a molecule that inactivates a gene known to

used less pain medication. September 2019 | The Journal of Healthcare Contracting

TRANSFORMING HEALTHCARE DOESN’T HAPPEN ON ITS OWN. It takes a spark, a unique vision to see better ways of delivering care and improving lives. At HealthTrust, we apply our unique operator expertise to accelerate change and improve provider performance. Learn how HealthTrust can help you turn your insights into action.

Be the Catalyst.

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JHC September 19  

JHC September 19