It may be time to return to specialty rehab nursing
PPS and focus on quality bring program full circle
The home care industry has changed so drastically in the past few years that it’s little wonder quality managers and administrators cannot keep up with the latest service trend. After all, the last they heard restorative nursing was out and the generalist nurse was in.
That’s likely to change under the prospective payment system (PPS) for fiscal reasons, but even more for the purpose of improving the quality of home care, says Janey A. Roach, RN, MSN, ONC, an advanced practice nurse for orthopaedics/rehabilitation at the University of Pittsburgh Medical Center Home Health (UPMC).
Home care agencies under the proposed PPS rule have a greater incentive to provide care for orthopaedic patients because Medicare recognizes that those patients are more costly, Roach says.
"We won’t know until the final regulations come out, but potentially we could be looking at $500 [or] more," she adds. "PPS will pay you more for three diagnoses of increasing severity in patient care, and the first is neurological, the second is diabetes, and the third is orthopaedics."
Soon after joining the UPMC home health agency two years ago, Roach hand-counted diagnoses of newly admitted patients at the agency for three months, and she found that 30% to 35% were orthopaedic cases. These included patients with osteoarthritis and degenerative joint disease, as well as surgery cases.
Despite this volume, the agency did not have a special training program.
"We still had a group of nurses who didn’t understand orthopaedics," Roach says. So she helped the agency form a specialty orthopaedic/ rehab team in February 1999.
It’s too soon to see the final results, but anecdotal evidence suggests that the specialty nursing team has already improved quality and saved overall medical costs, Roach says.
Illustrative examples
Roach provides these examples of how specialty orthopaedic nursing can be cost-effective and improve quality:
• Example 1: A patient in her early 60s receives a total knee replacement and stays in the hospital for five days. The patient has no complications. When the patient is referred to home care, there are four skilled nursing visits at a cost of about $135 per visit for a total of about $540. The cost is the same whether or not a specialty rehab nurse is sent to the patient’s home because the agency does not pay the specialty nurses a higher salary.
• Example 2: A similar patient has the same procedure and is referred to home care after a five day hospital stay. In this case, a regular medical-surgical home care nurse is sent to the patient’s home for four visits. On the second visit, the nurse notices a small amount of drainage on the patient’s knee dressing. But the nurse doesn’t call the physician because this type of drainage is very common with other wounds, such as surgical sites on the stomach. By the fourth visit, the drainage is still there, but it has not increased, so the nurse does not call the physician. Then the patient goes to see the orthopaedic surgeon for a follow-up visit, and the physician is angry to see the drainage.
In this case, the physician called the home care agency, complaining that he wasn’t notified about the problem. Because the prosthesis could potentially become infected with continued drainage, the physician had to wash it out and treat it with antibiotics. Then the patient needed an additional eight skilled nursing visits. The 12 visits cost about $1,614. The intravenous antibiotics, which were administered for 14 days, cost $2,100, and those costs do not include the additional surgical fee.
• Example 3: A similar knee replacement patient again is referred to home care after a five-day hospital stay. On the third visit, a specialty orthopaedic nurse notices drainage. This nurse knows from her training that any type of drainage at an orthopaedic surgery site is a cause for alarm, so she calls the physician. The doctor prescribes a seven-day, oral antibiotic and approves three additional nursing visits. The cost is $940 for seven visits plus about $20 for the drug, totaling $960.
Those examples demonstrate the importance of having a specialty orthopaedic team, for the patient’s safety and overall cost savings, Roach says.
Plus, a specialty orthopaedic team will reassure orthopaedic surgeons that a home care agency is qualified and capable of handling their referrals. Even one mistake could result in an agency losing a huge referral base, Roach says.
Here are some key aspects to the UPMC home health orthopaedic/rehab nursing program:
1. Recruit nurse volunteers.
The agency would not pay orthopaedic/rehab nurses a higher salary, and many nurses do not care to handle orthopaedic patients, so Roach sought volunteers, who were interested in learning more about orthopaedics and who wanted to increase their own marketability as a nurse who could handle all of the typical home care duties, plus a bit extra.
"My goal was to have these nurses see all of the orthopaedic patients, but certainly the most complex cases," Roach says.
Orthopaedics are explained during training
2. Provide training and orientation.
Roach held a four-hour orthopaedic orientation program, spending 2.5 hours lecturing about orthopaedic surgery and care.
For instance, she explained to nurses that just about everything an orthopaedic surgeon does involves metals in the body. If a patient has a fractured tibia, the surgeon puts in a plate and screw. Because of these foreign objects in patients’ bodies, there is a high risk and rate of infection, and the effects could be very serious. Any infection could quickly turn into a bone infection and sepsis; left untreated, this could eventually require an amputation.
"There are certain things you need to do as far as making sure wounds don’t become infected," Roach explains. "For instance, when a patient returns home with a total hip replacement, the patient is not allowed to shower or place any soap or water on the metal clip staples."
Nurses must make sure nothing is done to increase the chance of superficial infection that could spread to the patient’s joint, Roach says.
Take care to prevent long-term problems
If the joint is infected, the physician will have to take out the joint and wash it and put the patient on antibiotics for six weeks, sometimes even sending the patient to a nursing home.
"We’ve had chronic cases where they ended up without a joint or losing a leg," she says. "If you don’t treat these things meticulously, you could end up with long-term problems."
The last part of the orientation program involved lectures from physical therapists, an occupational therapist, and a speech therapist, followed by a question-and-answer period.
The training also included clinical observation of rehab care.
3. Assign orthopaedic cases to rehab nurses.
Rehab nurses at UPMC have the same productivity as other home care nurses because they handle regular cases, in addition to the orthopaedic and rehab referrals. But they are specifically assigned to a patient population that has immobility needs or who are deconditioned due to these diagnoses: head injury, spinal cord injury, cerebral vascular accident, multiple sclerosis, Parkinson’s disease, amyotrophic lateral sclerosis, chronic obstructive pulmonary disease, arthritis, amputee, upper/lower extremity fracture, post-hip repair/replacement, and post-knee repair/replacement.
The orthopaedic/rehab nurses complete all assessments of patients who are referred only for physical therapy and occupational therapy. They identify any skilled nursing needs to ensure complete care, and then review and reinforce the patient’s prescribed physical and occupational therapies and treatments.
4. Provide follow-up to training.
Roach conducts annual competency visits with the rehab nurses. She also reads their case documentation and observes their technique, providing additional training and education when necessary. Often, she personally visits a particularly complicated orthopaedic case. And finally, she holds monthly meetings with the rehab team.
The hour-long meetings include food, and they give the team a boost both in morale and education. "At the last meeting, we talked about PPS and how Medicare recognizes that orthopaedics in rehab is an important thing," Roach says.
Attention to detail pays off
All of the attention to training detail will pay off with physician referrals and higher quality of patient care, Roach says.
"Home care nursing has come full circle," she explains. "We had specialty training and then got rid of it because we thought it was too expensive." But now, for home care agencies to compete on the basis of quality, they’ll need to go back to specialty teams, she says.
• Janey A. Roach, RN, MSN, ONC, Advanced Practice Nurse for Orthopaedics/Rehabilitation, University of Pittsburgh Medical Center Home Health, 9400 McKnight Road, Pittsburgh, PA 15237. Telephone: (412) 366-1500. Fax: (412) 366-2581. E-mail: [email protected].
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