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Staffing models differ from site to site
Biggest challenge is turnover at adult day centers
The home health agencies participating in the Centers for Medicare & Medicaid Services (CMS) Medical Adult Day Services Demonstration had rules to follow regarding patient selection, partnership with adult day centers, and data collection, but they each were given the freedom to staff the program in the manner that worked best for their agency.
Because all adult day services centers with which the home health agencies partnered had medical staff, such as a registered or licensed vocational nurses in place, Doctor's Care Home Health in McAllen, TX, opted to designate case managers to oversee the adult day center staff's monitoring of the home health patients, says Mercy Flores, BSW, MA, social worker and demonstration manager at the agency.
"The case manager also sees home health patients and educates the adult day nurse about documentation," says Flores. The adult day nurses document their care for the home health patients in the demonstration project on paper forms that are picked up once each week by a home health employee. These nursing notes are added to the patient's home health chart, she says. Although the documentation is not as complex as the documentation required by the home health nurse, such as OASIS, the adult day center nurses do complain about the extra paperwork, she admits. "They are not experienced with this level of documentation, so there is a learning curve," she explains.
At Landmark Home Health Care in Allison Park, PA, home health nurses normally assigned to the geographic area in which the adult day center is located see patients at the center, says Kim Delp, RN, BSN, director of business development for the agency. "Usually, it is the same one or two nurses that go to the adult day center on a regular basis, so they get to know the day center staff and the program," she says. When the demonstration project started, the home health nurses visited the center to introduce themselves and become familiar with the day center's services, she says. Having the same people work with the day services center improves communication between the two organizations, she adds.
The adult day service centers and the home health agency rely on the Internet and voice mail to document services and maintain constant communication, says Sue Meier, RN, administrator of Landmark Home Health Care. "We use an electronic, web-based documentation system, so we are able to give adult day nursing staff access to specific patients' charts to enable them to make notes as they see the patients on days that our nurse does not see the patient," she explains.
The communications process also requires the adult day nurses to leave a voice mail for the home health nurse to alert him or her when a change has been noted, or a concern expressed by the adult day nurse, explains Meier. "This alerts us that the patient may require a home visit to follow up on the concern," she says.
There has been no problem finding staff to see patients at adult day centers, says Meier. "Our staff members enjoy seeing patients in the adult day center," she says. "They like the environment and like being able to see several patients in a shorter period of time than required when they drive from home to home."
The staffing challenge that has been faced during the demonstration project is the turnover of nursing staff at the adult day centers, says Flores. There is a learning curve for proper documentation and assessment of home health patients that are now at the day services center, she says. "Turnover requires additional education by the case manager, or even the case manager's presence at the adult day center, to see patients in the demonstration project while the day services center tries to fill the open spot," she explains.
The adult day services center's nursing staff does have additional responsibilities during the demonstration project, because nurses may see 19 patients during the day rather than five or six, points out Flores. "Eighty percent of the adult day centers in our demonstration project area gave nurses a bump in pay to compensate them for the extra responsibilities," she says. This incentive is important to keep in mind if the project is approved for all home health patients, because adult day centers will see more patients that require daily monitoring, she adds.