It is Nursing-Yoda I seek!

Nurses General Nursing

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Specializes in MLTC.

Hi Nurses,

I need some advice, on an assignment for an "Issues in Health Care and Professional Nursing" BSN class. In our first class we were asked to identify an issue we've identified in nursing, and the professor asked those of us that are working to choose something in our related fields because she would like to see us be able to do something with the project at the end of the semester. My currently employed is as a field intake assessment nurse by a Medicaid Managed Long Term Care (MLTC) company.

I'm putting my disclaimer here - I am in no way trying to offend anyone who may work in any of the fields mentioned further in discussion, I am only going by what I have noticed in my personal experiences, and I am only mentioning it as a way to complete my assignment and hopefully improve patient care in the process.

Up until 2 weeks ago, my primary function was to go into a patient's home, determine eligibility for the plan based on a functional assessment, and collect relevant data pertaining to services that might already be in place to establish continuity of care. I have repeatedly noticed a deficiency in the quality of care provided in settings that lack direct supervision, and I had already been pondering this issue in my head for some time when the project was presented. Once I brought the topic up in class two of my colleges agreed and shared experiences where they identified the same issue.

After identifying the issue, we then had to relate the issue into a professional nursing issue discussed in our textbook, and write a 1-2 page log introducing the topic. There is a series of logs due throughout the semester, which build off the previous, adding new literature and research to validate our claims and provide a possible solution. Of course this issues was not one that was listed in the text, so I spoke about whistle blowing, discussing the fact that no one involved in the continuity of care are reporting anything, internally or externally. I discussed reasons nurses wouldn't whistle blow, and made a suggestion for Press Ganey-type patient reporting. Not my best work, but I had an extremely hard time finding supportive literature. I partially regret picking something so challenging, but I am very passionate about improving the quality of community care given to the Medicaid population.

In a meeting at work today the term "Home Care Worker Wage Parity" kept coming up so I questioned my boss and she provided me with a lot of information. Apparently, as part of Medicaid reform, NYS recognized that home care workers are grossly underpaid, and they set up a provision to increase the wages. I have worked enough "unskilled labor" positions to understand the correlation between fecal matter pay and fecal matter services. I asked my boss if the NYS law addressing their pay was recognition of poor quality, and she confirmed.

I know this wage parity stuff fits here, but I'm not sure where to go with it. All home health aids come from either LLHCSAs or CHHAs, and work under a nurse. If there is a care quality problem an aid, then there is a care quality problem a nurse who oversees a patient, identifies poor quality care, and does nothing about it, or provides such poor care herself she doesn't think there is anything to report. I have not been able to find literature to support these claims, and the few articles I have come across that seem relevant are always in journals that require $40 before you can even read the abstract.

How am I going to prove this is a problem that needs to be addressed by more then a $2/hr salary increase? I feel that not having any bedside or clinical experience might be hindering my ability to have realistic expectations for the roles I'm discussing, and I don't want to look like a fool. I would really appreciate any input/guidance/advice anyone can offer, because I'm racking my brain here!

Could you do an anon survey presented to multiple home health agencies? As a home health/private duty nurse I can confirm that patient care is not what it should be. I don't see an increase in pay fixing the problem. I think nurses get comfortable and know there is no one there to supervise them. I personally think that if random, unannounced visits to the patients home by a supervisor would definitely keep nurses on their toes. I have been hesitant to report things due to fear of retaliation and increased work hostility. There are anon ways to report, but rarely is anything done about it.

good luck!

Specializes in MLTC.

Thanks for the suggestion! I would have to ask the teacher if I could conduct my own study, but I can't see her saying no.

Specializes in LTC, Agency, HHC.

My question is, where is the case manager? They are to oversee the staff on their caseload, and do a visit/skills check once a month. Before I got my RN, I had one case manager do that.....at 11pm and I was told by the previous nurse he was coming.

Absolutely, HHC workers are way underpaid. That is because the company has to make a profit, and medicare/medicaid only pays so much. Excuse? Yes. Reality? Yes. When I first started doing pool in 2008, they wanted to put me on the PDN case I am on now, as a LPN at $16/hour for days. This year, the pay is $17/hr for LPN's on days. How much does the facility charge for a PDN hourly?....$70. Yep. $70 an hour for a nurse.

I personally make more $ a hour than nurses with same experience at the hospital so that isn't an issue for me. I think it defeats the purpose of a supervisor showing up if the nurse knows their coming. My kids would never be in trouble if I warned them I was about to check on them.

Also, I don't think increase in pay will fix anything. Lazy nurses are lazy nurses. They will cut corners regardless of how much they are paid, however the increase in pay might attract better nurses.

Specializes in nursing education.

Hi OP.

For one thing, never pay for an article. If you are in a BSN program you can request the article from the librarian- often they can get it for you.

You have identified an immense problem! I would narrow it down further for this project. One of the articles might help you identify a sub-problem that will focus your lit search and have a more manageable solution.

Lastly, your statement "I feel that not having any bedside or clinical experience might be hindering my ability to have realistic expectations for the roles I’m discussing, and I don’t want to look like a fool." You have specialty experience with home health in the Medicaid population, so it sounds like you actually have more, not less, standing on this issue.

Here is an article from the Georgia Public Broadcasting Network. It discusses a review done by the Office of the Inspector General of the U.S. Department of Health and Human Services and seems to be related to your concerns.

A Third Of Nursing Home Patients Harmed By Their Treatment

Specializes in MLTC.

As far as nurses for MLTC, we are like case managers, but with no direct authority over the companies we contract to provide services. We were told we could be subject to a surprise visit from a supervisor during an appointment in the field, but that has never happened to me. As far as when I notice poor care or something alarming coming from an employee of another organization, the first few times I reported it to compliance in my company, the way we were taught to respect the chain of command, nothing was ever done. Even one time I had to report something to APS, I was told not to use the company's name, to let them figure it out. I am no longer in the field, but when I was I started just calling the companies directly and filing complaints on behalf of Hospitals I didn't really work for, and non existence family members with threats of calling social services. It's really messed up out there, and most of these patients aren't educated enough to understand they are not getting what they need/are entitled to.

Specializes in MLTC.

I agree!

Specializes in MLTC.

I would never pay, I have tried my library's data base, and I actually requested 2 articles, but I haven't heard anything back yet. I also appreciate that others agree that this is an issue. Sometimes at work I feel like I'm standing out on the ledge alone. And in school there are very few students who are out in the field, even most of the teachers don't understand most of what I'm taking about. It's like I can hear the eye-rolling when I speak. That's probably why I was second guessing myself. Thanks for the advice, I will try try to identify some sub-problems and work from there! I really appreciate the tip!

Specializes in MLTC.

OMG! That's great! Thank you!!! I will also look around the DOH website more!

Specializes in MLTC.

Actually, this is one of the problems I'm having. That article is on nursing homes. The point of MLTC and home care is to provided the same services in the home to prevent the need for a nursing home. Employees of nursing homes do have direct supervision. In my opinion, the reason for poorer quality in those types of facilities is a direct result of the patient load the nurses are expected to care for. Either way, you pointed to look at the DOH. Thank you!!!

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