How to talk to clinicians: Part I

I had just arrived in a Home Health agency that was struggling in many areas (fiscal, census, productivity, etc.), but staff satisfaction and retention was particularly problematic. The Director of Clinical Services (DCS) gave me quick tour of the central office. On the bulletin board in the break room I saw a posting that stopped me in my tracks. It had the current average HHRG score (in dollars!) and the goal for the dollar amount the DCS was shooting for.  “If they meet the target they get a shaved ice machine for the office,” the DCS excitedly explained, while I silently screamed inside.

Setting aside the obvious ethical and regulatory nightmare here, this DCS was also demonstrating a perfect example of how NOT to talk to clinicians and support teams. In part one of a three-part series we’re going to briefly introduce two effective strategies for training and motivating staff in any health care setting: 1. Always remember why your staff are working where they are. 2. Train to develop elite teams.

These strategies are informed by lessons learned from what over 50 years of research has taught us about what really motivates employees.

Why are they here? College Nursing and Allied Health programs have become incredibly competitive. The GPA requirements are as high, or even higher in some cases, than what’s required to apply for some Med Schools! Our clinicians have lots of other career options – many of which would have been much more lucrative and less stressful. They chose this path because they want to help people. If we tie our messaging in with this altruistic motivation it increases confidence in the organization and leadership, improves engagement and, most importantly, it works!

One study showed changing signs in a hospital from “Hand hygiene prevents you from catching diseases” to “Hand hygiene prevents patients from catching diseases” increased hand washing compliance 33%! Our clinicians and support teams care deeply about our clients and want to help them. In fact, that’s why got into health care and why they stay, despite the ever-increasing demands piled on them.

It is an inescapable fact that health care in the United States is a (big) business. There is no denying that. If we don’t watch the bottom line, our organization will not be around to serve our clients, and our staff should understand that reality. However, improving the quality of care is the only real way to gain a competitive advantage in the marketplace, improve reimbursement, achieve compliance… all the factors that effect the bottom line!

Train to create elite teams. Humans are social creatures and we need a sense of belonging. Simply put, we want to be part of a team. And we really are motivated when we feel we are a part of a highly successful team. I’ve been in health care a long time and have seen many examples of individual and team success. I don’t think I’ve ever seen as much enthusiasm in the workplace as I have the few times I’ve been in the room as a team received the news they had earned a deficiency-free Survey. This is a rare accomplishment that really makes teams feel they are in the top tier.

I’ve worked with hospital systems all over the country and the “Life Flight” (or watever they are called in your area) teams often take on almost mythical status. They usually have a very competitive selection process, rigorous training and are regarded as the “best of the best.” They have the cool uniforms, gear, logos and branding. I was at a hospital event once and they were giving out baseball-style trading cards with each of the team members on them – some kids even asked them to sign the cards! These flight crews work long and undesirable hours, routinely see horrific tragedies and have very stressful working conditions, but they usually report a very high level of satisfaction with their jobs.

We can’t all ride in the helicopter, but we all need to constantly build team identity and cohesiveness – and it helps to be unique and special. I’ve had great success, for example, having teams pick colors and mascots like athletic teams. Collective goals are often more effective than individual goals.

Our organizational culture should aim to be the best in the industry and we should reinforce this goal with our messaging and daily interactions. In fact, we should start in the hiring process. The hiring process should be rigorous and thorough, and we should clearly state our high expectations from the encounter on. Staff are motivated as much by what we expect of them as what we will do for them.

Trust the research. Despite over five decades of research, most of us are all still stuck on now disproven methods of motivation (definitely confessing my guilt, here). Rewards, bonuses, “if/then” incentives, carrots and sticks… all of these myths of motivation have been proven not only ineffective, but they often actually decrease employee performance and engagement. So, what does the research – and the example of the most successful companies – tell us really works? Author Daniel Pink in his brilliant book “Drive” summarizes the findings into three main factors: autonomy, mastery and purpose. Autonomy in healthcare is a massive challenge and opportunity too complicated for the space available here (stay tuned).

The two strategies mentioned above are strong tools in helping our people feed their need for mastery and purpose. There is much more to consider regarding staff communications and training, but these two approaches can be transformative and epic in and of themselves. As if that’s not enough, reconnecting with our passions and developing elite teams also makes for a really, really fun work environments.

References

Patients’ Health Motivates Workers To Wash Their Hands

https://www.psychologicalscience.org/news/releases/patients-health-motivates-workers-to-wash-their-hands.html

Doctor Mike Evans’ “Med School for The Public” YouTube channel

https://www.youtube.com/user/DocMikeEvans

Improving The Patients’ Experience

http://www.stmichaelshospital.com/pdf/quality/QIP-2017-18.pdf

Drive. The Surprising truth about What Motivates Us

By Daniel H. Pink

http://www.powells.com/book/-9781594484803

TED Talk: The puzzle of motivation.

https://www.ted.com/talks/dan_pink_on_motivation/transcript

A Motivation Expert Explains Why Businesses Go About Motivating People All Wrong – And How To Do It Better

https://www.businessinsider.com/dan-pink-businesses-motivate-people-all-wrong-2017-1#according-to-pink-the-way-businesses-motivate-people-to-solve-those-problems-is-completely-misguided-they-rely-on-incentives-like-bonuses-perks-and-free-stuff-while-all-the-science-suggests-those-dont-work-4

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These are a few of my favorite pods...

Podcasts are perfect for those of us who work in home health, travel for work or drive to multiple sites. Also great around the house, exercising, etc. These are my current favorite professional podcasts (updating all the time). Please leave suggested Pods in the comments. 

Big Picture Health care, trends, innovations

·        Relentless Health Value. Definitely my favorite big picture healthcare podcast

·        The Future of Healthcare

·        TEDTalks Health
I      Inside Health Care - NCQA
       The Accad & Koka Report

·        The Healthcare Policy Podcast

·        2 Docs Talk

·        Outcomes Rocket

·        The #HCBiz

·        The Business of Healthcare Podcast

·        Conversations On Healthcare

Home Health and home care

·        Home Health Minute

·        Disrupt (Home Health Care News)

Allied health podcasts

·        Lifestyle By Design (Karen Jacobs)

·        Seniors Flourish

·        Occupied

·        Everyday Evidence (AOTA)

·        NRSNG

·        Geriatric Nursing

·        Nursing uncensored

·        Senior Rehab Project

·        APTA Podcasts

·        PT Inquest

·        Speech Science

Compliance, Regulatory, and Healthcare ethics

·        1^st Talk Compliance

·        Compliance Mastermind

·        Compliance Perspectives

·        Compliance Expert

·        Second Opinion (KCRW) healthcare ethics

·        OIG Podcasts (only on website)

·        CMS podcats

·        Joint Commission Quality series

Leadership, work culture, etc.

·        The Future of Work

·        Voices In Leadership

·        Wharton Business radio
       Harvard Business Revue IdeaCast

·        The Business of Healthcare

·        Healthcare Value Network

·        Coaching For Leaders

·        Health Communications Partners

·        The Tim Ferris Show

Client engagement, empowerment, loosely related, etc.

·        Patients Have Power!

·        Hidden Brain

·        The Voice of the Patient

·        The Healthcare Policy Podcast

·        Patient Engagement Podcast

·        Inside Health (BBC)

·        JAMA Editors’ Summary

·        This won’t Hurt A Bit

·        TEDTalks: Science and Medicine

·        NEJM This Week
       Freakonomics Radio

The Sherpa can guide us to medical necessity, skilled services and patient involvement!

Two of the toughest concepts for even the best nurses and therapists to deeply understand and document have recently become even more critical and will continue to be among the most important concepts in health care in the future. I’m referring to balancing true patient involvement with providing skilled care based on medical necessity. Clinicians and agencies who can master these concepts, make them the center of all their encounters and document them well will be the leaders of the industry in the future, impress the regulators and will have the best outcomes. These concepts are complex, but they can be easily understood and remembered through a simple metaphor: the Sherpa.

No westerner, even the celebrated Sir Edmund Hillary, has ever reached the summit of Mt. Everest without the help of a Sherpa (Himalayan mountain guide). The Sherpas have the unique skills, expertise, training, knowledge of the mountain and environment, and experience to help thousands of people conquer Everest and other tough mountains. They show their clients exactly what to do, and they know when to encourage them to press on, when to slow down and when to stop in place. They know when to revise the plan. Does that sound familiar? Consider Medicare’s definition of skilled services: services that require the skills of a clinician to be safe and effective, due to the inherent complexity of the service, the condition of the patient and accepted professional standards. Combine that with the expectation that we constantly reassess the effectiveness of our interventions and revise the plan when needed, it becomes clear - our clinicians are Sherpas leading patients to summits they could not reach on their own. They are (medically) necessary guides!

However, the Sherpa can’t climb the mountain for the climber. The climber still as to do the work. The climber must pay attention, receive, understand and implement the education. This represents true patient involvement. We can’t just rely on handouts without training and passive, superficial “patient education.” Our clients must be deeply involved in the planning process, fully understand and integrate the training, and take every step up that mountain. Our clients and the mountain climbers need the clinicians/Sherpa, but they have to actually do it themselves.

I’m not sure what the documentation requirements are for Sherpas, but I suspect we might have a tougher mountain to climb than they do in that regard. By teaching our clinicians to document what they did as skilled, professional guides and describing what obstacles they helped the client overcome; detailing the steps the patient performed, the training they integrated and how they progressed each step of the way and tying this together, we can tell a compelling story that’s easy to understand and appreciate. Our clients and our clinicians make an amazing team, and clinicians must proudly document their individual and joint achievements. The Sherpa metaphor is a great daily reminder of how to do that.

The cruelest "nice" question

How many times have you seen a senior level leader ask a subordinate who is struggling, “What can I do to support you?” I know I’ve asked that question dozens of times, at least. On the surface, it sounds incredibly supportive. But it can bring more unintended negative effects than the positive help intended – especially if it is ill timed.

The question can become loaded if  the junior leader is feeling lost in the weeds. Believe it or not, just asking this question can further stress her/him out –  they are looking to us to have some answers and this question can make it sound like we don't have a plan! Did the cavalry arrive, but forget ammunition? It can also seem like just one more thing to figure out, to ponder, to distract.  It can be one more question s/he feels pressure to have a good answer for. Since leaders are performance oriented by nature, they feel like they need to come up with the “right” answer to every question posed. A skilled senior leader might account for all of this and accommodate, but there is still a fundamental problem with this question. It shifts responsibility from the senior to the junior leader. Essentially, we are telling her that not only does she need to improve her performance, but she’s got to figure out the senior leader’s job as well!

If they knew, they would have tried it already! In the Health Care business, we usually promote from the clinical ranks. Our front-line managers are usually pulled from the top 5% of the field - the best of the best – are highly driven and have achievement-oriented personalities. If you’ve got the right person in the job, they’ve already tried everything they know how to do, asked everyone they respect what to do and may be in panic mode racking their brains about what to do next. Simply put, if they knew what they needed from you, they would have already asked and if they knew what to do, they wouldn’t need you!

What are we really here for? We are in our positions because we have years of experience and training and can see things the junior leader can’t see from her perspective - her “stripe on the beach ball” * We know things she wouldn’t even dream of asking. We have access to resources she doesn’t know exist. We’ve been in similar situations and we’ve seen others in similar situations. We are there to synthesize all of that into tangible support. We bring ideas and actions the junior leader can’t request, because she can’t fathom.

So, I can’t ever ask? Don’t get me wrong, we actually should inquire to find out if there are any resources we can get or logjams we can clear – eventually. We should ask what we can do to help, but not at first, not as a primary strategy and not until we’ve done a whole lot more.  It should be used as a fail-safe. Yes, we have the authority or the resources to move hills and mountains the junior cannot. If we can cut through red tape, get quickly a question quickly answered, expedite a request or authorize a resource, we can almost magically help. We just have to be careful how we ask – and more importantly, when.

When to ask. I’ll bet you’re familiar with this scenario: a senior leader (or a team from “corporate”) arrives in town or calls to help a struggling program or agency. The junior leader knows why you’re there, and even if you have an excellent relationship, she is dreading the encounter to some extent. Leaders like to achieve, and they when they know they’re not, and it’s tough place to be in. So, the senior asks to go over the plan. We poke holes in it (as we should), question it, remind them (as if they didn’t know) how much is riding on the turnaround, and offer a few suggestions. If we precede that or even follow that up directly by asking what we can do, it’s likely going to bring more frustration than relief. Let’s hold off a little….in fact, I think it would be more effective if we hold off critiquing the plan as well.

No ifs, ands or buts. Our message to junior leadership needs to be clear: we are in this together and we are by your side. As long as you are trying in good faith, I’m there. And by the way, I’ve been where you are, and I know how to get through this. Just asking what we can do to help implies, “I’ll help, as soon as you tell me what you need.” No. I’m here to help right now. We will figure this out. Let’s get to work.

First, roll your sleeves up. Consider this example. I had earlier arrived from the airport in a struggling agency. The newly promoted Director was in it deep – a multiple-paged plan of correction in response to a recent poor state survey, the financial report was bleeding red all over the page, productivity bad, admissions down, key positions open, at least two clinicians in need of performance plans and an unhappy office team. The day before, by phone, I had helped him develop a list of important tasks and presently we had just finished putting them on the dry erase board and numbering them by priorities. The Senior Vice President had been on a later flight and when she arrived, she gave the Director a coffee cup filled with his favorite candy, a hug and asked for a work space. She set up quickly and looked at the dry erase board. She didn’t ask for an update, go over the plan and, importantly, she didn't ask what she could do. She quickly looked at the list and attacked the stack of resumes and began setting up interviews and doing phone screens (recruiting for the key positions was high on the priority list). She also pulled up the EMR and Plan of Correction and started doing some of the required chart reviews.

Soon the Director looked like a new man! He was visibly relieved, and the pep was back in his step as the three of us worked that day on his priorities. The three of us got a lot done that half day. We took him out to diner that night and causally discussed the plan and went over what was working and what wasn’t. Later that night the VP and I discussed OUR plan to support the Director.

Now we can ask. The next morning, I met with him and started out with what I, the VP and the company would do to help. We went through the plan together – including poking holes and suggesting edits – and revised it together. Finally, I did ask him if there was anything else we could do for him. He couldn’t think of anything at first, as he profusely thanked the VP and I. Then he remembered a capital expense that was caught up in red tape. We ensured him we would (turns out it only took two quick phone calls). I asked as a final check, not a staring point. I used it as a final reassurance to ensure we’d uncovered very stone, we respected his viewpoint and to reinforce I was there for him.

The bottom line. We expect leaders at every level to assess key clinical and business issues and develop a plan of action. Since supporting our first line supervisors is probably the most vital role we play in mid-level or senior leadership, why would we model anything less? Asking what we can do to support a junior leader can be an effective reinforcement, closer or reminder of our support. It is less effective and potentially counterproductive an opener or primary tactic.

*A reference to the “beach ball” metaphor that illustrates how we can only see things from our own perspective without training, effort and deliberate compensation. Susan Scott explains it this way in her brilliant book Fierce Conversations “Think of your company as a beach ball. Picture the beach ball as having a red stripe, a green stripe, a yellow stripe, and a blue stripe. Let's imagine that you are the president of the company. That's you standing on the blue stripe. The blue stripe is where you live, every day, day after day. If someone asks you what color your company is, you look down around your feet and say, ‘My company is blue.’ “

We'll have to make our own path, but there are lots of navigators wanting to help us!

Those who aren’t in education – and some in education that just don’t “get it” – often lament that our educators have had to take on the roles of social worker, cook, life coach, friend, parent, clothing supplier, psychologist and wear many other hats. They are being pulled in too many directions to teach. But those who truly understand how kids (actually all humans) learn is interwoven with so many other aspects of their lives. Learning isn’t isolated from the rest of their lives. These other ways kids need to be cared for certainly present challenges, but they aren’t distractions. They are the keys to real education and growth.

For far too long, we in health care have ignored the research – or thrown our hands up – that has told us we can’t cure people just by treating signs and symptoms. There are still many who still fight it, but the momentum from researchers and payors pushing us has finally become too strong to resist. Maybe we had to be pushed, but make no mistake we are well past the edge and are falling fast into the world of population health, whether we like it or not. So what now? To stop the free fall we need to find sky hooks, grab ahold of a branch, find a soft spot to land…. I’m using multiple metaphors because it’s going to take multiple solutions. There won’t be any silver bullets, but I think we have already discovered a few varieties of special sauce. There is a massive body of research and many of innovators already leading the way. For example, in her work and in this enlightening TED Talk, Susan Pinker explains the real reason women live longer than men almost everywhere around the globe. She is speaking loudly and clearly to those of us concerned with population health – IF we’re ready to listen. Watch this and share it with a friend in health care. If that person’s reaction is, “We can’t manufacture friendships for clients” or “It’s not our place to play social match-maker” or anything that doesn’t sound something like “Wow. Okay, what can we learn from this? What can we try….” Well, that friend won’t be leader helping healthcare get to where we need to go. Don’t discourage your friend too much, we’re going to need all the help we can get and we all won’t be leading. But these are not the voices we can count on for inspiration. Find “educators” who “get it,” and are inspired by the challenge, even if they are not sure yet how to get there, and maybe even a little afraid. Assure your friends we’ll bring them along and there will be plenty of places for them if they’re willing to change. But resistance is no longer an option. It’s time to listen to the research and get moving! Exciting times indeed!Listen to this!Please watch this Pinker TED Talk!

Oh yes you can go there - in fact, you must!

Imagine a quality improvement meeting at General Motors and the participants never even mention the cars? How about a Chef and her Sous Chef trying to improve the quality of the restaurant’s food, but they never talk about what the cooks are making? Absurd, right? Yet way too often, when we talk about improving quality and outcomes in Home Health, we avoid talking about the most important factor – the specific methods and care the clinicians actually provide in the visits.

Home Health leaders and Quality Assurance groups usually rely on a standardized set of steps - data is analyzed, charts are reviewed and assignments are handed out. Every organization has its own take on the process, but most of the steps are similar. Improvement plans – usually highly focused on documentation improvements and reports - are developed, training is conducted and we agree to check in at a later date. The closest we get to practice is usually shadow visits, but they usually focus on generalized principles (clean bag techniques, customer service, and maybe wound care). Don’t get me wrong, these tried and true steps are the distilled wisdom of years of practice and work. They work. Recent research has validated the importance structured and standardized care (for example, Atul Gawande’s Checklist Manifesto is a great read on this topic). But in home health quality assurance, they are rarely transformative, rarely challenge our practices and often allow us to avoid the elephant in the room.

Case conference is the closest most of us get to actually critically examining the actual care provided to the client. But time restraints, professional courtesy and event focused discussions (e.g. discharge planning, recert decisions, etc.) keep us from doing a deep dive into the place where the rubber really meets the road: the specific treatments, approaches, techniques and interactions between our clinicians and our clients.

Good documentation is absolutely critical. Process measures actually do measure things that make a difference to our clients’ recovery. But how our clinicians spend those precious few minutes we’re given in each visit has to be inspired, thoughtful, based on best practice and critically analyzed if we’re truly going achieve transformative care. And even the most skilled documenter can’t hide pedestrian or ineffective sessions.

So why are we so hesitant to jump right in the area we instinctively know is the most critical factor? A deeper study of current research and some focused questions for study are needed. But I’d like to share a few observations and theories:

·       “Our clinicians are the best and they know what they’re doing.” Maybe they are the best, and I hope your hiring and mentoring programs weed out at least the sub-standard. But the best of the best in any field not only constantly evaluate their own performance down to the micro level, but they also have coaches and mentors helping them break down their work, consider alternatives, critically think and suggest new ideas and approaches. It’s not only Pollyannaish to expect our clinicians to do this completely on their own, but it’s a huge burden to place on their already over-worked shoulders. They need us for more than documentation training. And ultimately, and unfortunately, you might have to make changes. There’s simply no room in home health anymore for the thin-skinned or the complacent. You might have some people on your team that just aren’t up to the challenges of the current environment.

·      " Medicare (or insert another all-powerful entity like “corporate” or “insurance”) makes us do so much we don’t have time for quality.” There’s no doubt that the requirements continue to increase, and the time allotted stays the same or decreases. These are truths, but they’re not insurmountable. These are the conditions of the playing field for all, not excuses for mediocrity. The best of the best overcome these obstacles. We need to help our clinicians figure this out. They need specific, practical training on the skills needed in his environment: point of service documentation, assessment tools, time management, inter-personal skills, etc.). They need to be skilled in these “soft skills” to free them to treat effectively. It’s also important to remind them that these required measures often are effective in guiding care, not just administrative irritants. For example, full vital sign checks help ensure we don’t miss subtle changes in condition, and unusual findings should focus our approach – potentially saving time. Mandatory triggers to notify a physician or collaborate with others on the team certainly require extra time. But they also serve as a critical time out to reassess at a potentially critical time in the clients’ recovery – or lack thereof. It costs time today, but makes the rest of the episode run more efficiently.

·       Clinicians as journalists. Nothing frustrates me more than an assessment that is actually just a summary of what the client or caregivers told us. Like a news report. Heck, if that’s all we had to do, we could have an administrative assistant call the client or send them a questionnaire. We are billing our payors for actual skilled, expert observations and assessments of ADL performance and medical condition observation and analysis. You didn’t do a head to toe assessment if you can’t tell me the color of your client’s underwear. You have no business turning in an assessment of toileting and bathing if you didn’t go in the bathroom. Unfortunately, and unbelievably, these practices are all too common. If you’re in a leadership position, you have to know these short-cuts are common in the field and you’d better be darned sure it’s not happening under your watch. I don’t care how many stars your agency has, if this happens in your agency your clients and payor sources are getting ripped off.

·       “I’m a nurse (or OT, or non-clinical, or whatever). I can’t question the skills of an OT (or PT, or nurse or whatever).” This common attitude requires a delicate response. How’s this: Male bovine feces! If you’re in a leadership position, you are expected to study up on best practices of all the elements of the services you provide in any industry. Health care is no different. Luckily there is a plethora of resources for you. The ANA, AOTA, APTA and ASHA are the best places to start. They all have websites that are treasure troves, but you can also pick up the phone and call them. You should have a posse of expert collaborators from all the disciplines you can turn to for advice. We have to read the professional journals. Call a professor at your local University that credentials the disciplines you oversee. Now when it comes time for counseling and coaching the clinicians to improve what they are doing in the visits you must use tact, excellent coaching skills and respect. Sometimes it helps to deliver the message with someone from the same discipline, but you must feel comfortable having these conversations solo as well. Make sure you’re role modeling best practice in leadership, strategic planning, agency improvement and other areas where your job requires you to be an expert.

·        Can’t see the trees though the forest. Often while we’re following our tried and true processes, and making sure we do all the things we’re supposed to do we become overly focused on our known and presumed solutions and we kill creativity and innovation. As healthcare quality and innovation expert Roy Rosin reminds us, “Fall in love with the problem, not the solution.” Don’t skip the tried and true, but don’t rely on it exclusively either. Meditate on the problem – break it down, look at it from different angles and brainstorm it before you pull out your checklists.
What have you seen? Please contact me or leave a comment about your thoughts and obeservations.

I’m lucky enough – and old enough - to have worked in leadership positions in many organizations from coast to coast. Here’s an almost universal truth I’ve discovered. You can’t truly improve quality unless you look at your episodes that demonstrate outcomes improvement, stabilization and decline, then drill down to the actual care provided. The majority of the time – not always, but usually – we record a stabilization or a decline, the area was either not fully assessed, not treated, treated through simulations or handouts, treated obliquely or haphazardly or the approach was never changed during the episode despite lack of progress. The physician is rarely brought in to discuss lack of progress in these poor outcome cases. I realize this is heresy in some circles – but I think this accounts for more poor outcomes than misunderstanding of OASIS scoring and intent or documentation.

Therapeutic exercises are valuable support to recovery, but to improve bed transferring, the clinicians have to spend a lot of time working with the clients on bed transferring – in bed! Skilled wound care is an art and a science – but what happens beyond the dressing is just as important. Therapy-only cases need just as much focus on the medical, medication and overall health issues as the most medically unstable episodes heavy on nursing visits. I promise you – look at what the clinicians are doing with their clients and the answers will unfold like a revelation.

Nothing in Home Health is more important than what happens in the home. We must look there for the answers. 

Leadership requires courage. We must rise to this challenge.

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Mother's day Special: In defense of Mama Medicare

For those of us in Home Health, Medicare often seems like a very stern, demanding, tough-love type of father figure. But I think just the opposite is actually true. She can definitely be strict and demanding, but to really understand her you have to realize she's actually more like a loving mother. Can she be meddling, nit-picky and over involved at times? Sure. Does it feel like she's being unfair on occasion? Definitely. But she really does care and wants the best for the family. And she's actually pretty darned smart.

To understand Mama Medicare, you just have to keep these factors in mind:

Mama Medicare's heart swells when all her children play together nicely. She wants to see us all collaborating, communicating, working together, helping each other and building on each other's strengths. She wants us all to double check each other to make sure nothing's missed. She wants us to hang out together and conference, problem solve and bring out the best in each other (coordination of care).

Mama wants you to have nice handwriting. You need to write it all out and very clearly. She really wants to hear from us. Don't be a stranger, drop mama lots of notes. (Quality documentation)

Follow Mama's rules. Sometimes we just don't understand why our parents have such crazy rules. Why can't I have ice cream for breakfast? Mama Medicare actually does a really good job explaining her rules (CMS training updates, alerts, MLN Matters, conference calls, etc.), so try to listen and learn. Take advantage of these resources and do your homework. But sometimes you just have to follow the rules whether you agree or not.

Mama's on budget. Medicare's a working mother, and her boss - Congress - is very stingy! We often feel overworked and underpaid, but that’s nothing compared to the enormous responsibility of caring for nearly all our nation’s elders with soaring health care costs, while the pay is dwindling. Every day she has to do more with less. If you're going to spend the family's hard earned, limited resources, you'd better clearly explain why it's needed. She wants to make sure that money is there for the next child in need as well. (Medical necessity),

Tell Mama how it's going. She wants to hear about life's ups and the downs. She knows things don't always go well, but when they don't she wants you to have a plan for changing your approach up. (Document progress, explain and solve barriers, constantly re-asses) Mama doesn't expect you to be perfect, but she wants you to keep trying until you get it right.

Mama wants to hear all about your day. Sit right down. Tell mama what you did today. Tell her all about it. Paint a picture so she feels like she was there. Don't leave any details out. (Client-centered, individualized, detailed documentation)

Mama wants to brag about you. Go ahead and brag about your accomplishments. Tell Mama in detail. Tell her about all those skilled services you provided. Don't leave anything out. She's so proud of you and your degree. Use all those big highfalutin professional words (skilled action verbs, medical jargon, full names of techniques and tests). And speak up clearly. No mumbling (unapproved abbreviations) around Mama!

Mama wants her babies at home. Help mama keep everyone home. Not in the hospital, at the emergency room, in rehab or in nursing homes. Keep them all at home and take good care of them there! She knows we all need a little help every now and then, so help her help all of us.

So this Mother's day, let's show this abused, neglected, taken-advantage of, over-worked and underappreciated Mama some long over-due love. Happy Mother's Day Mama Medicare. You may get on our nerves some time, but we know you love us and we love you back!

Note: I realize this article reinforces and makes light of traditional gender stereotypes and assumptions about roles. I want to rewrite this in the future. If you have suggestion please contact me.