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Nurses need to understand their new roles
As home health educators lead their staffs into 2000, they must show how staff roles are changing in this era of increased regulation and managed care. Home health nurses are responsible for more documentation and outcome-based care planning and for the financial effects of decisions made in the field. They need to know more than ever about the limits on the care they provide and the intricacies of reimbursement, especially with Medicare moving next year to a total prospective payment system.
"Because of all the reimbursement changes that Medicare is putting through, you have to look at each visit as having much more meaning than it ever did," says Margo Zink, RN, BSN, MN, EDD, CNAA, a home care consultant in Timonium, MD.
A focus on cost-effectiveness can be difficult for nurses, who may have been taught that their only concern should be quality care, says Elizabeth Hogue, Esq., a Burtonsville, MD, health law attorney. "Part of the education that needs to go on now with nurses is that . . . their job is not just to provide quality care but to provide quality, cost-effective care," she says. "That is especially true in home care, where nurses are really the gatekeepers of the Medicare home care system. But helping nurses see that there are limits and boundaries to home care is really, really tough."
One area Hogue says needs attention is assessment of those patients who should not receive home care. Diligent attention to the criteria needed for successful home care — the ability to meet a patient’s needs at home, a reliable caregiver or ability to self-care, and an adequate home environment — can ensure patients are in the best setting for treatment. It also can prevent accusations of abandonment if an agency decides later it can no longer treat a patient. "When patients don’t meet those three criteria, they just gobble up resources that the agencies just don’t have any more," she says.
A new time crunch
Reimbursement changes also are driving an increased focus on outcome-based care — using realistic endpoints to manage delivery of care, often in an abbreviated time frame, Zink says. "Unfortunately, I think a lot of staff still look at a Medicare time frame, and then when they get patients for whom the HMOs only allow them four visits, it’s difficult for them to adjust their goals. You can’t project for nine weeks if you don’t have those granted to you, and I think that places staff in a real ethical dilemma.
Education can help nurses set realistic goals that include an accelerated patient and caregiver teaching component.
"They need to look at doing more work teaching family members to assume that role more quickly. They can’t just think about it. They have to make a decision right away and start their teaching," Zink says. "The whole time crunch is really difficult to deal with when, in home care, you never had that time crunch before."
She says the greater emphasis on self-care requires keener observation skills and a willingness to make tough choices on the part of both nurses and aides. "I think the issue of teaching vs. doing is something that nurses especially have to adjust to. By virtue of the nature of nursing as sort of an altruistic, helping-type profession, to say to this 80-year-old woman, You’re going to learn how to give your own injections,’ is a more difficult thing than to say, I’m going to come every day and give this injection for you.’
"I think it goes with being an aide, also. The home health aide has to give a bath and must determine whether Mrs. Jones can go in and do a partial bath in the bathroom. It’s easier for her to not ask Mrs. Jones and just give her a bed bath."
Hogue says the problem is compounded by the fact that patients and families don’t always understand the role of home care. They may believe that the home health nurses will perform the same role they did in the hospital — taking care of all the patient’s needs.
"During the admission visit, staff should be very direct with primary caregivers about the role they must play," Hogue says. "They must further make it clear that if the primary caregivers fail to fulfill their role, patients simply cannot remain in home care."
The time crunch has another result as well: It places a premium on precise, detailed documentation, not just to safeguard reimbursement but to ensure that care is smooth and consistent, with no gaps or overlaps in treatment or training.
"For example, the nurse says [in the patient’s chart] that she’s going to teach the patient how to do an insulin injection," Zink says. "How does she go about it? How does she assess the patient? If I’m reviewing the chart, what are the steps? Can I tell the steps she’s going through to do that?
"Every visit has to blend with the next one. If I go out and do this teaching after this other nurse has been doing it, and I don’t have a clear picture if she’s finished steps one and two, then I’m either going to be repeating it or I’m going to be skipping over something," she says. "Each visit has to be much more closely interlocked with the previous visit and the future visit."
The drive to provide cost-effective care and to shorten care plans coincides with the continuing referral to home care for patients who are sicker with more complex ailments. The convergence of all of those factors places a greater burden on case managers, who are responsible for coordinating care. Zink says the concept of case management should be better defined for nurses and more rigorously emphasized.
"I was just working at this big agency, I would say a sophisticated agency, and the nurse who was supposed to be the case manager didn’t even know if a contracted physical therapist was still on the case or not," she says. "I said to this person, Aren’t you the case manager?’ And the response was sort of, Well, am I supposed to know that?’"
She says training should emphasize the accountability of a case manager to ensure the patient’s goals are met by the entire team and that disciplines are not in conflict with one another.
With more technically advanced medical equipment and medications introduced every year, even a well-trained nurse can find it hard to keep up. Agencies should be sure they’re supporting staff by providing continuing education before nurses are asked to use such advances in the field, Zink says. "If they’re getting high-tech cases, they’re getting high-tech equipment, the system needs to continually make available to nurses who are not familiar with technology a way to feel comfortable and not put them in a liability standpoint and just expect them to learn on the job by themselves."
The advantage of some of those advances is that they actually make the care easier, more readily lending themselves to use by patients or family members.
"It’s a trend we’ve been seeing for a number of years," Zink says. "It’s amazing what patients or family members can do themselves, with a nurse monitoring it, because of the advancement of say, infusion pumps. It’s much more user-friendly and can be done safely by a layperson."
As home health agencies continue to draw staff from hospitals, educators need to focus on preparing those newcomers for the different environment in which they’ll be working. Zink says she has worked with good, qualified nurses who still had problems because they hadn’t gotten the necessary grounding in the particular challenges of home care. "I was working with a wonderful nurse, a cardiac specialist, but she had never been oriented to home care. She had the assessment skills, a wonderful manner with patients, but she didn’t know how to document effectively because no one had taken the time to mentor her in this system."
Hogue says agencies need to continue to place focus on educating their employees about rules designed to combat Medicare fraud and abuse. "They need to have a corporate compliance plan, and part of the corporate compliance plan is that employees need to receive 2½ to three hours of education every year about compliance issues."
Staff often don’t understand that regulators don’t have to prove staff knowingly claimed services that weren’t provided, Hogue says. "Court decisions say that if enforcers can prove that providers knew or should have known of a pattern of fraudulent conduct, enforcers may conclude that staff had intent."
Hogue says nurses need to know that every health care provider, regardless of his or her position, can be held responsible for fraud and abuse compliance. She cites fraud charges brought against a home health agency in Florida regarding billing for visits that were never made. In that case, action was taken against managers at the agency and individual nurses. "I know that people feel a little bit jaded about this now, but it remains very, very important."