Tips on teaching staff about prospective pay
Change is scary, so be flexible
So you were just getting used to managed care entering the private insurance market, and now all of a sudden the government says it is switching the way it pays for Medicare.
What do you do?
A prospective pay system might mean more work and more documentation, but the process will be easier with advice from experts who have already made these changes.
"Everybody here in our agency knows it’s good to work together and be cooperative and to keep the information flowing," says Mildred Prosser, RN, MPH, president and owner of Homestaff Health Care Services in Norwalk, CT.
"The key aspect is teaching staff to be flexible," says Susanne Fairman, RN, BSN, PHN, MBA, CNAA, chief operating officer of Hospital Home Health Care Agency of California in Torrance.
Prosser, Fairman, and Jill Sproch, RN, quality improvement manager of Homestaff Health Care Services, offer the following tips on how to teach staff about the prospective pay system:
• Emphasize clinical pathways and outcomes in care.
"People need to be introduced to the concept of standards of care; they also need to be familiar with clinical pathways and outcomes," Fairman says.
Outcomes are the desired goals.
For example, a diabetic patient might have three desired outcomes: One is to teach a patient how to become independent in controlling his or her diabetes through medicine and diet; two, the nurse could set a goal of bringing the patient’s sugar to a stable level within three weeks of being discharged from the hospital; three, the patient is checked in two months, and the patient is able to verbalize the signs and symptoms of complications of diabetes.
"You would want to monitor the patient’s progress as well as the progress of any key significant others or family members," Fairman says. "We would want them to be a part of helping the patient achieve the outcomes."
The clinical pathway is the course of treatment that will lead to achieving the goal.
"You have got to be thinking in the initial start of care about what you anticipate and expect in the way of resource consumption to achieve your goals," Fairman insists. "What is that patient’s plan of care going to be?"
• Stress the importance of accurate data when filling out assessment forms.
The OASIS assessment tool contains items about patient status. Those require the home care professional to choose a response that identifies the status of the patient in the same factual way no matter who has completed the assessment.
The agency is involved in the OASIS project, conducted by the University of Colorado in Denver, as part of the Outcomes-Based Quality Improvement.
"It’s so important that your data is accurate," Sproch emphasizes. "What OASIS says is that all of these items have been tested so that any discipline from a nurse to occupational therapist will be able to effectively respond with the same answer."
Homestaff Health Care’s start of care assessment form has more than 80 specific questions for staff to answer. Here’s an example:
Ability to use telephone: Refers to ability to answer the phone, dial numbers, and effectively use the telephone to communicate. (Staff should check one of two boxes before each question: Expect, Current.)
able to dial numbers and answer calls appropriately and as desired;
able to use a specially-adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers;
able to answer the telephone and carry on a normal conversation but has difficulty with placing calls;
able to answer the telephone only some of the time or is able to carry on only a limited conversation;
unable to answer the telephone at all but can listen if assisted with equipment;
totally unable to use the telephone;
NA Patient does not have a telephone.
UK Unknown.
The numbers checked after each answer are counted and tracked to follow the patient’s progress in various areas. The same questions are repeated in the follow-up and discharge assessments.
"There shouldn’t be any difference in interpretation of these questions," Sproch says.
"Professional staff has stated that the assessment is more thorough now," she adds. "You can get a clearer picture of where the patient is at in his or her care."
• Help staff prepare for the increase in documentation, and ease their change into a new way of thinking.
Sproch and Prosser knew they would be asking a lot out of the staff, so they turned the new project into a celebration. When it was launched March 1, 1996, they sent out birth announcements and threw a party for employees.
"Our theme was this was almost like giving birth, preparation for a baby," Sproch says. The party included balloons, cake, and even a baby cradle.
The agency will hold another celebration on the anniversary date.
Sproch has found that it’s important to remember how change is rarely a constant upward spiral and to remember that staff will need lots of encouragement.
"With all this data collection you sometimes get into a little rut," Sproch explains. "It’s like a river flowing; you may get stuck up on a rock every now and then, but you have to keep reminding yourself that why you’re collecting this data is to really show what we can do in home care and how home care makes a difference. That will get you back in the flow."
To keep the flow will require continuous education.
"It will be a continuing education responsibility here," Prosser states. "It’s an ongoing education program we need to address at least once a year, and I see that as a constant."
• Have nurses ask themselves if this service could be provided by a nonprofessional.
"The clinicians who are going to have difficulty are those who are focused on achieving patient wellness rather than helping them achieve independence," Fairman asserts.
Here’s an example she gives: A patient is seen daily by a nurse for minor wound care, but on the weekends the family is asked to make the dressing changes. "Traditionally, this was acceptable because the agency had the ability to monitor the patient’s progress by seeing the patient during the week," she says.
The nurse’s care might not end for months under the traditional system. However, under the prospective pay system, the nurse would ask his- or herself whether the patient’s family could provide the dressing changes during the week as well.
"There was no rhyme or reason to why the nurse went in five days a week, and the family went in two days a week except there was mutual convenience for the agency and the family," Fairman says. "I think we have to ask ourselves as clinicians to be more critical about these procedures: Is this one that can be safely performed by nonprofessionals? If so, why are we going in there five days a week?"
• Teach nurses to call in social workers, physical therapists, occupational therapists, and other professionals at earlier stages of a patient’s care.
"We see a reluctance to aggressively use the multidisciplinary team to manage the patient early in admission," Fairman observes. "I think traditionally we have gotten those other disciplines involved, but we’ve done it more at the agency’s convenience, and maybe there’s a three-to-five day delay."
Under a prospective pay system, home care agencies will need to enlist help from other disciplines from the start, she says.
"It’s up to the nurses to recognize that they need to bring in physical therapists, speech therapists, occupational therapists, psychiatric nurses, nutritionists, and pharmacists," Prosser says.
It’s hard to change attitudes
Nurses will have to ask themselves whether the family would become more independent more quickly if the social worker was involved and made two or three visits during the first 10 days of home care.
Sproch gives this example of how this might help the patient become independent more quickly: "Here’s a patient who has a wound, and the patient is not able to put on his clothes," she says.
So the patient needs an aide to visit him daily. But under the new system, the nurse might refer the patient to an occupational therapist, who could help the patient learn how to dress himself using adaptive equipment. "So maybe the aide doesn’t need to come in every day, and that’s the whole purpose, to make the patient independent," Sproch concludes.
This change isn’t as easy to implement as it might sound because it’s hard to change the attitudes of some professionals, Fairman warns.
"To some people this is threatening because they feel they know what is best for the patient, and with a true interdisciplinary case management approach, you’re going to have other professionals challenging your plan of care," Fairman says.
Still, there’s no going back to the old way once the prospective pay system takes over, she adds.
"It’s a question of teaching nurses how they can be professionally responsible and accountable but still feel professionally satisfied," Fairman asserts. "Those who understand and accept this change generally don’t have a problem with it. But the lone rangers who don’t want anyone questioning their expertise will find this threatening."
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