1. Piskor, Barbara MPH, BSN, RN, NEA-BC

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Skills I developed as a home healthcare clinician have helped me consistently in my activities as a consultant. As a direct care clinician, I referred to the persons I cared for as patients, and as a consultant, I refer to them as clients, but the same basic skills are used. The geographic territory covered might be larger and the transportation mode more varied, but similar problem solving and interpersonal relationship skills are utilized.


Flexibility and a sense of humor help in both settings. Rearranging schedules to accommodate new clients on days with a full schedule is common. Driving (or flying) in all types of weather and through construction detours is a challenge. Teaching effectively is required whether the goal is a good clinical outcome or a successful survey. Interacting with persons from all socioeconomic and cultural backgrounds is a necessity. Using evidence-based practice whether clinical or business-related is a must.


A typical week may find me addressing strategic plans with a board of directors in a large paneled conference room or planning for a new agency start-up with a single owner around a small table in a basement home office. Activities vary from planned conference calls and scheduled consulting sessions to emergency calls from clients dealing with a patient crisis situation or a surprise visit from a surveyor.


Along the way to my consulting role, I functioned as a visiting nurse, supervisor, administrator, educator, new business development director, surveyor, and back-up relief for almost every managerial position in an agency except for chief financial officer. My settings included home healthcare, hospice, and private duty (skilled and nonmedical). I learned what I could from chief financial officers. I then added graduate education in finance to my clinical and administrative background so that I could bridge the potential or real chasm between clinical activities and business operations.


My consulting practice includes 50% general agency or specific service analysis with follow-up related to operational processes, compliance, training, and quality improvement, and 50% new business start-up or new service development.


A sample weekly schedule.


* Sunday evening: Travel to client's geographic location and final preparation review of resources that were sent to client in advance and agency background documents.


* Monday and Tuesday daytime: Conduct a mock survey with small-to-medium size home healthcare agency. Activities include:


* Morning conference with administrator, clinical director, owner, and key management staff.


* Patient home visits with multidiscipline staff members.


* Patient record review and critique with clinical staff.


* Policy review with management staff.


* Human resources file review.


* Quality assessment and performance improvement (QAPI) review.


* Follow-up staff interviews, for example, billing, compliance, marketing.


* Provide a final exit conference highlighting findings and tentative recommendations.


* Monday evening:


* Answer e-mails and calls received during day from other clients.


* Develop preliminary report for mock survey findings from first day.


* Tuesday evening:


* Travel home.


* Answer e-mails and calls received during day from other clients.


* Wednesday all-day. A day at my home office in sweat pants and a tee shirt or casual clothes with constant coffee and a bathroom nearby is valued. I do remember the days of searching for a clean restroom between patient home visits.


* Complete report on mock survey with findings, recommendations, and helpful resources.


* Preplanned conference call to hospice client related to their QAPI Plan using skype or audio only, based on client preference.


* Write a first draft of a new policy required by a recently released governmental bulletin. Ongoing monitoring of all Medicare and Medicaid bulletins and listservs is required to identify proposed and final changes. Read, read, read. The only secret to this is signing-up for all relevant listservs, participating in related webinars, and subscribing to professional journals. Staying on top of e-mails received from key listservs is a priority or crucial changes will be missed.


* Work on a client's application for Medicare-certification as a provider for hospice. E-mail to client to clarify status of the state licensure receipt.


* Review clinical record in preparation for a Medicare appeal. E-mail summary and recommendations to client.


* Answer an urgent call from the new director of a nonmedical, home care client regarding a patient who experienced a fall. The caller asks "who all do I need to report this to"? Apart from family and physician (if necessary), three different governmental agencies plus internal reporting is the answer. We laugh about the need to complete three different forms in duplicate and all within 24 hours. Gently, I remind her that there is a policy on it in the agency policy manual with related bulletins attached that provides details for reporting.


* Answer e-mails with requests for information throughout the day. Examples of questions: One of my aides had a needle stick from emptying garbage of a patient who self-injects insulin. Whoops-it wasn't on the aide's care plan and there is no evidence of patient counseling; I think we just had a Health Insurance Portability and Accountability Act breach. What should I do?; we are losing business to a competitor because we don't "promise" an aide visit every day. Is that a new requirement?


* Complete a final review of handouts and content for educational session to be provided on Friday.


* Thursday Morning: Attend professional meeting regarding palliative care. The new Advance Care Planning billing codes may be helpful to qualified clients. Note to self: Recheck Medicare B guidelines. Place on "to do" list.


* Thursday Afternoon:


* Meet a prospective client over coffee. Yes, marketing of consulting services is necessary just as it is for agency survival.


* Drop-off items to a local client and say "Hi" to staff. Maintaining warm, professional contact is as important in consulting as it is for the clinician to demonstrate compassion and caring.


* Friday Morning: Local client on-site training program regarding the home healthcare face-to-face requirement.


* Friday Afternoon: Finalize handouts and related documents required for next week's consultation activities and e-mail them to clients.


* Saturday: Catch-up with e-mails, reading, and writing ... for example, a legislative column written quarterly for my district nursing organization, professional journal reading to keep up-to-date, and Web site browsing to make sure a major bulletin or the final version of Medicare condition of participation wasn't missed during the week. Or sometimes, working on Monday morning's deadline!



My week is varied. It is interesting and challenging. It finds me driving, communicating, teaching, documenting, and responding quickly to the needs of the client. Does this sound similar to the clinician in home healthcare or hospice?