What if........

hoolahan, ASN, RN · Nov 23, 2002

I would start with a much better orientation of the nurses, so they truly understand the regs for HH and medicare, managed care and medicaid. Work on documentation and give regular inservices.

The intake dept needs a MAJOR overhaul, I would steal NRSKaren from her current employer, much easier than trying to do it myself!!

I would only take critical new admits on weekend, and would change to a call system instead of nurses working weekends. We would be closed on Holidays...period. Pt's who call in for help would be advised to seek tx in the ER. Mean? Maybe, but MY nurses would be spending Christmas w their families, every year, not just everyother.

I would start with hiring a database admin, or at least consult, so we could develop a database that we could pull lots of info from, which would be a huge help to the nurses and the QA dept. Each nurse would have at a minimum a palm, and at best a laptop, so that we could carry the whole case load on a teensy unit. Make it a palm w the e-mail and phone capabilities, that would accomplish a lot, with the least amt of money out. Everything possible for documentation would be a check list, and b/c we would have such an ecellent database, nurses would never need to re-write name addy med rec # SSN etc over and over on all the diff forms, it would be programmed to print w this on top pf each page. A nurse would be able to generate PT ref, MSW ref, etc, just by tapping on the palm screen, and selecting from drop-down menus.

Lastly, nurses would be able to wear jeans, and decent shorts in the summer. No more uniforms, unless they wanted to wear them for sanataion purposes. Also, all office staff and admin could wear jeans too. As long as their work gets done, there would be no rigid dress codes. As long as it is clean and decent it's OK.

Maybe I'll think of more later.

LoisJean · Nov 23, 2002

Excellent response, Hoolie! Now, let us say you have aides on board. What would you provide as far as initial training and continued education in terms of inservices, etc.? What would be the minimum requirements you would have for your aides?

Let's say you have LPNs/VNs--how would you utilitze them?

Come on, the rest of you lurking around here....start posting your ideas!! IF YOU owned the agency you are currently working for-- or from experience you have had working for HHC Agencies--what would you change?

Peace,

Lois Jean

Traveler · Nov 23, 2002

I agree about better orientation so nurses can better understand Medicare, private insurance issues, etc. I would also like to see the nurses have some type of computer where we could access recent labs, etc. while in the field.

As far as dress codes, I think it depends on the areas that you service. I'm in a rural southern area and the patients like to see the nurses dressed like nurses. We (fortunately) aren't faced with any real threats of being mugged because people think we have drugs or needles. I have actually found that it helps to "look like a nurse" when I get lost in some remote location. People are much more likely to assist when they see how I'm dressed.

I am lucky enough to work for a company that has a great office support for the nurses in the field, but that's not always the case with some. I would make sure of this in my company.

Ann

hoolahan, ASN, RN · Nov 23, 2002

Well, not sure about where you are Lois, but here, there is a standard curriculum the aides have to follow. I dont think I would do training, too expensive, and a hassle. There are local vo-tech schools that give the program. I may offer a bonus to put them through the program if they agree to work for me for six months.

For cont ed, same thing goes. In NJ all HHA must have 12 hours documented CEU's per year. They have to have Basic CPR, abuse, infec control, etc, same mandatories as us, and only so many hrs can be by self study. I would give as many self studie's as I could, and have bi-yearly health fair to get all other CEU's done, or do a jeopardy game for mandatories, fun stuff like that.

LPN's? I wouldn't have a special plan for them, they would do the same thing as the RN's except for case managing. Maybe have a LPN in intake department as well. Other than that, I don't really see much of a difference between what a LPN and a RN do in HH.

Lois, do you have other ideas for LPN's in HH?

LoisJean · Nov 25, 2002

Okay, guys: so far tops on the list is better/ore orientation regarding insurance regs/types of insurances; second is a more contained, easier to access, method of retrieving data. Also, a programmed data base would be created specifically for the particular agency needs; Then there are suggestions for increasing the self-study requirements for aides-a health fair is an excellent idea. The dress codes would be more suited to the nurse's personal choice- not an agency required thing; LPNs might be utilized in the intake department and would serve as the RNs assistant in the field-as is the rightful role and best utilization of an LPN.

Okay, now lets say that you have come to believe that time is money and money is time. You find that an inordinate amount of time is taken up in the area of paper work. Now remember: this is YOUR agency. Where and what would you cut out regarding paper work? Hoolihan sez that she would devise a check list--that's good, but there's more still that is time consuming--what would you change in this area in order to increase your time factor? Let's say you came up with a way to decrease the amount of paper work/documentation by 1 hour--what would you do with that extra hour to increase your profits for the day? Maybe a better way to say this is, 'What would you eliminate in order to increase profit?

Do the same thing with scheduling. Where and what would you change within the scheduling scheme to save your agency money?

Ann, let's say that through funding cuts one-half of your office help is eliminated. This is your agency. What would you do to keep your office viable?

Your responses are still important.

Peace,

Lois Jean

hoolahan, ASN, RN · Nov 25, 2002

Lois, you are making us have to THINK! Dont you know that can hurt my little brain??

Well, some would say I am cutting off my own foot, but I would cut out the Liaison's in the hospital's. Yes, they bring in referrals, but in my short expereince as a weekend supervisor, we had no trouble getting referrals from discharge planners depserate to leave on time on Friday afternoon. It seems to me that the hospitals like the Liaison's b/c they write up the referrals! Just have them call in referrals to the intake dept. Of course NRS Karen would have them so well-educated, referrals would be no less than perfect when done this way

Well, what would I do with the extra hour? The most obvious choice is give each nurse an extra visit, but I have a feeling that would go over like a lead balloon. So, I would make them all participate in QA activities, and maybe cut hours in the QA dept.

By being closed on weekends and holidays, we would save alot of money already by not having to pay on-call and differential pay. Though I have to admit, if we did hospice, we'd have to have call for that arena only, it is a must.

I honestly don't know that much about business to answer this question intelligently. BUT, I will say Lois, that I picked up a neat book on how to start up your own small business, and they said to cut out one bit of overhead would equal profits rather than increasing your product. So, it seems you know what you're talking about!!! When everyone has answered, I want you to tell us what you would do, OK? :)

Traveler · Nov 25, 2002

Wow Lois......you're making some big cuts. Okay, if one half of my office help is eliminated because of cuts I'm going to try to work out something with some prn office help. Where I work things come in waves. We're slow for a while and then we get hit hard. I would try to train some hha's to do some of the office work (getting admission packets together ahead of time, re-stocking teaching materials, etc.) during slow times in visits.

A biggie with me is the way we now do admissions. It is ALL on paper from scratch. I can't tell you how much time I waste writing the patient's name, # and date at the bottom of each page for admissions, re-certs, etc. I guess one of my pushes would be good computerization. Start up for that would cost but time wise it would save on busy work.

I don't know if you all figure out HHRG's on your admissions. I do just so I can better plan visits. We're not required to do this though. We have a nurse who has been doing admissions and re-certs for quite some time and doesn't understand how the Oasis is tied to reimb. I dare say that we've lost some money due to this. The education is very important for the RN's.

Ann

LoisJean · Nov 26, 2002

Now, Linda, you know there isn't enough money in the world to pay Nurse Karen what she would demand for salary!!- :eek: (okay, Karen, I know you're lurking around here somewhere-I can hear you breathing!)

Linda sez lose the Liasion! Good job! You are going to have an LPN doing the intake- and she/he is going to feel honored for the position and will do an excellent job for far less $$. And, Linda is going to use the extra hour to put nurses to work doing QA- this is good--saves on mileage $$, too.

Ann sez that there is a loss of $$ because one of her emploees doing admissions and recerts does not understand the tie in between Oasis and reimbursements. What exactly is she omitting to cause loss of $$? What are you going to do about it, Ann- this is YOUR agency--you can't afford a loss. So what's the solution?

Also, Ann- You definately need that program! But, you cannot afford to pay a professional programmer- what's another way?

(What are HHRGs? I'm not familiar with the initials).

What about mileage reimbursement? That means thinking about territory traveled by nurse's and aides and how mileage impacts your agency's budget. What would you do to cut costs in this area?

Keep helping me out--can't tell you how much I appreciate this.

Peace,

Lois Jean

hoolahan, ASN, RN · Nov 26, 2002

Lois, I forget what HHRG stands for, but it IS directly linked with how you answer the questions on the OASIS. There are 23 questions on the OASIS which make up the HHRG. Three categories of questions Clinical, depends on diagnosis, so diabetics get abhigher reimbursement rate, Functional, so those who need more assistance get a higher reimbursement, and services, so if you have PT, OT or any other disciplines, you get a higher HHRG.

When Medicare went back to PPS for billing, they pay a lump sum, for which the agency has to budget their services with. So, the higher the HHRG, the larger the budget.

Let's say a nurse answered all the functional questions as pt is more or less independent, yet PT and PT are needed. Well, she is responsible for a lower HHRG, and the agency will likely lose money on that case. Same thing if you put a HHA in there just for a prima donna who thinks she should have it b/c it's her right as a benefit of Medicare. IF the answers don't calculate a high enough HHRG to support all the services you are providing, you lose money. Some agencies have sup's who are supposed to review the OASIS for consistency, and some have a OASIS nurse reviewer, but even still, mistakes slip by. That is why it is so critical for nurses to truly understand PPS and hone their assessment skills. Like better be sure that nurse checks the feet of that diabetic pt before he c/o a sore spot on his heel three days later, which would require supplies and Rx, and since it wasn't in the intial assessment, the agency may lose money.

Home Health Columnist / Guide · Nov 26, 2002

Lurkin indeed and spending time with my family. Drove to Delaware to meet Cheerfuldoer so now playin catch up.

If LPN's are permitted to accept verbal orders in your state (not permitted in PA) then I would include in intake department; otherwise, can't use them as orders for home care ARE verbal orders received from physician's representative. LPN would need to have homecare experience to understand nuances and not accept pts clearly inappropriate for care.

We combined the OASIS and Nursing Intake assessment into one booklet type document that has name one first page only.

Clinical note is two-page checklist includes pain assessment and care plan. We worked to eliminate duplicate documention.

Have gone to laptops BUT this new system has SO many boxes to go into to document info rather than see it laid striaght out like were used to, it can get anoying. Not yet inserviced on Nursing documentation area so can't comment if quicker. We been using computer for intake all info and takes 10-15 min to data enter compaired to written form takiing 5-7 minutes to complete. I can get statistics out of system easier, so will see how it goes.

HHRG= Home Health Resource group and is driving force behind payment. Despite having all 7 clinical managers (=nursing (superviors who manage teams of field nurses/therapists grouped acording to zip codes) be heavily inserviced in OASIS, DRGS, and coding who review each initial OASIS and POT but still don't see the missed boxes or non- matching answers. Our QA RN reviews and codes each chart at present with Intake nurses assistance (agency has 1000+ to review monthly). What we did to help decrease errors is come up with an OASIS grid: If wound care question answered yes, then following questions must be answered yes or no not skipped, 500---on O2/ vent----need to have orders on POT and Respiratory asessment O@ question checked. ( can't remember OASIS #'s tonight.

RE ADL's: if some areas answered yes, then PT/OT would be requested if not recent homecare. DOes diagnosis support PT/OT in home or does additional qualifier DX need to be added. You can't immagine how many nurses don't understand the connection btwn homecare Diagnosis, services ordered and care plan!!!!! Spend the time and money upfront during orientation and review at team meetings OASIS/HHRG's. Finally seeing improvement 2 years later---are RN's PT do do chart review with down time and I think that has been the BEST way for them to learn--make it review of own AND others charts.

Will write more later when brain fresh.

LoisJean · Nov 26, 2002

:confused: Holy Moley, Karen! Before reading your post here I was awake- now I'm brain dead! Blew an artery or something.

Well, there was a time when LPNs could accept verbal orders- but that small duty, (and time saver for the RN), was taken away from us- among other things--here in Mi. I read with interest an article in Nursing 98 (I think) about LPNs challenging the BON in their State to change regulations regarding some restrictions. After checking this out with my State's LPN Association I discovered that it would take the majority of our rank and file plus an act of god to achieve this. Not to mention support from enough RNs to make it stick. I got the distinct feeling from the president of our association that it was too much of a big bother!

At any rate-- this is YOUR agency. YOU own it. So how are you going to cut costs? Where will you start?

By the by--glad you're home. Missed you:kiss

Peace,

Lois Jean