Preparing staff for home care’s future may be your most important task in 1998
Experts offer advice on how to handle changes heading your way
Education managers may expect many changes in 1998 as the federal government and managed care companies exert more pressure on home care providers.
Starting next month, unless someone in the home care industry can convince Congress to change its mind, home care agencies will be forced to drastically reduce or eliminate care for patients who had been receiving venipuncture as their skilled care. (See story on venipuncture change, p. 6.)
The American Federation of Home Health Agencies predicts that hundreds of thousands of Medicare beneficiaries will lose all of their home health care as of Feb. 5 because of this provision in the Balanced Budget Act of 1997 that eliminates venipuncture as a qualifying skilled home health service.
However, Rep. Nick Rahall (D-WV) has introduced a bill, H.R. 2912, that would repeal the provision. The Rahall bill also would require the Department of Health and Human Services (HHS) to conduct a study within a year to find out how many Medicare beneficiaries qualify on the basis of a need for venipuncture and how much fraud and abuse is actually involved in the provision of venipuncture. Also, the bill would require HHS to determine how much it would cost states and beneficiaries to pay for replacement services for patients who no longer are able to get their blood work done at home.
More changes to watch for
Other changes that will have an impact on home care agencies in 1998 have no deadlines and may affect agencies in some states more quickly than others. These changes include the following:
• training nurses to provide highly skilled care to wound patients, cardiac patients, and perinatal patients;
• teaching patients more complex skills in fewer visits;
• relying on critical pathways to increase consistency in the quality of care and to assure managed care companies that the number of visits is necessary;
• training clinical specialists to work in a home care environment since agencies will be hiring more nurses from acute care to handle the increasingly sick patients;
• providing more self-teaching packets and video education seminars to accommodate staff who work evenings and weekends;
• establishing internships for new nursing school graduates because there will be fewer opportunities for them to train in a hospital setting.
So you see, your work at educating staff and patients will be more important than ever in the coming year.
The thin line between an agency surviving the rocky changes and falling into the dangerous current may depend on how well agencies teach their employees, experts say.
"Training is crucial to home care agencies making the transition to caring for the more complex patients," says Marjorie Bauman, MS, RN, president and chief executive officer of Johns Hopkins Home Care Group Inc. of Baltimore.
"So you need nurses who are highly experienced, well-educated, and who feel very self-confident in making more rapid decisions on more acutely ill patients and more unstable patients," Bauman says.
Home care agencies that wish to prepare and educate their staff for changes brought about by managed care and Medicare should pay particular attention to certain trends, Bauman and other experts advise.
Here are the highlights of what is coming down the pike:
1. Agencies will treat sicker patients.
"There’s an increase in outpatient surgery and in the level of technology used in the home," Bauman says. This trend already is being seen from coast to coast.
"The patients now being taken care of at home are medical-surgical patients who used to be in the hospital," says Faye-Ellen Lane, RN, BSN, MSA, director of home care for Cabrini Medical Center Home Health Agency in New York City. The agency serves Manhattan, Brooklyn, and Queens.
Problems may arise if Medicare payers force agencies to reduce the services provided to these more seriously ill patients, Lane says.
"When homebound patients have reduced services at home, what happens is they have to be readmitted, typically through the emergency room," Lane explains.
Home Health Plus in West Covina, CA, also has begun to take care of sicker patients, although managed care has not yet had much effect on the agency’s patient population.
These sicker patients have included people who have had major cardiac surgery and previously would have been handled in an acute setting.
"We’re seeing wounds you didn’t see before," says Linda Walker, RN, nursing supervisor for Home Health Plus, an agency that serves suburban and urban residents in the eastern half of Los Angeles County.
"We need people who are specialized in different areas, and we have to make sure case managers are well-rounded in what they do," Walker adds.
Personal Home Care Services Inc. of New Baltimore, MI, has changed its philosophy in anticipation of managed care trends and now focuses on teaching patients to manage their own diseases, says Larry L. Ruehlen, RN, EdD, educational development specialist/corporate for the hospital-affiliated agency that serves most of southern Michigan from nine offices.
"So the primary focus of our visits is education," Ruehlen says, adding that while the agency still does assessments, wound care, infusion care, and offers other services, education has to be a top priority.
Many agencies will need to hire more specialists to handle these patients, or they will need to find consultants to teach staff how to care for these patients, Bauman says.
2. Greater numbers of home care nurses and aides will work nights and weekends.
"In the past, many home care agencies scheduled visits between 8 a.m. and 5 p.m., Monday through Friday, and they were on call on weekends," Bauman says.
"Now home care agencies are opening cases much more often in the evenings," she adds.
This is because the agencies are taking over the high-tech care of patients who have been released from serious outpatient surgeries or hospital stays. The agencies need to be prepared to visit the patients as soon as the patients are sent home, and this could be in the evening, Bauman explains.
The challenge for home care educators is to find times and different ways to educate and train these off-hour employees. "You have to take education to them," Bauman suggests.
Here are some examples of how an education manager may do this:
• Use tele-conferencing and video-conferencing for teaching staff who are unable to attend inservices at the home office.
• Create self-learning packets that nurses and aides could read, take a quiz on, and return.
• Hold some inservices in the evening for staff who work those hours.
• Put educational software in a laptop computer for nurses to use for self-learning.
3. Everyone will need to be cost conscious.
Too few home care agencies understand how much it really costs them to provide an hour of nursing care to a patient, and a big challenge will be to figure out how much it costs and how they can reduce it, experts say.
The industry’s entire focus has been on charging for services based on the visit because that is how Medicare traditionally has reimbursed agencies, says J. Gary Bowers, CPA, of Bowers & Associates in Timonium, MD. The company provides reimbursement and financial management consulting services to home health agencies.
Managed care has shifted the focus to focusing on how much money it costs per hour to provide care. This cost needs to include everything from the nurse’s wage to the office supply expense, Bowers says. This cost has to be understood if an agency is to survive under capitation contracts, Bowers says.
Capitation means the home care agency receives a set amount of dollars to take care of the entire population insured by the managed care organizations, Bowers explains.
This is very different from the fee-for-service model in which the agency is reimbursed for each service it provides.
Under capitation, a home care agency has a strong incentive to reduce the costs of providing care and to reach patient care goals in fewer visits.
"And it’s going to be critical to understand the utilization patterns of those populations and the cost of services given to those members that require health care services," he adds.
This could mean that nurses and other home care staff will have to change their mindset about how they provide care, says Margo Zink, RN, BSN, MN, EDD, CNAA, a home care consultant in Timonium, MD.
"The mindset has to change to a much more comprehensive picture from the beginning to end of care, and nurses will have to look at how they may more effectively utilize each visit," Zink says.
Once an agency develops a cost system, which means it has figured out the true cost of providing each hour of service, then it is in a better position to negotiate with a managed care payer, Bowers adds.
This is why it’s important for nurses and other staff to understand how to reduce costs while improving outcomes, he adds.
Bowers acknowledges that this is difficult. "They don’t want someone telling them to make decisions that appear to be based solely on cost," he says.
"So you have to design efficient treatment protocols and get people to buy-in to that," Bowers adds. (See story on switching to protocols, p. 4.)
4. More acute care nurses will enter home care.
"What is particularly difficult is there are a lot of nurses laid off in the acute care setting," Lane says, adding that many of them may seek jobs in home care.
But, she explains, they may have difficulty switching from a task-oriented focus to a community health nursing focus, so the education manager’s role becomes critical.
While these high-tech nurses are needed in the home care setting, they will need to be trained to think about the safety and social-psychological issues that arise more frequently in the home care setting, experts say.
"Home care is a new location for many of them to work, so some of them are not comfortable with working outside an acute care setting and being out there without the support of having someone immediately down the hall," Bauman says. "It requires a different level of thinking."
Another challenge is there will be fewer hospital jobs for new nursing graduates, Bauman says.
"It used to be a home care company wouldn’t employ a nurse who didn’t have one year of medical-surgical experience in the acute care setting," Bauman says. "Now you have nursing school graduates who are having trouble finding jobs in the acute care setting."
Home care agencies may need to hire some of these new graduates and find new models for training them. These could include providing internships or nurse residency programs in the home care setting.
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