New Director of nursing for a start up company

HeySis, BSN, RN · Feb 17, 2011

I have worked for a company for 12 years and they started a Home Health. I now am the administer for them. We are a NFP and our leadership tree starts with the board of directors, CEO, myself then the DON. So the DON works for and reports to me. She directly supervises the clinical staff.

DId they give you a job description? You should have one so that you know what you can be held responsible for. Do you have to make decisions r/t payroll? reimbursement? Are you responsible to oversee any aspect of claims? How about if they are rejected for any reason? If you google HH DON positions, you will see some job descriptions that should help you.

Make sure you get OASIS training! So important, many State HH associations will hold training seminars. I send as many staff as I can each time.

Remember your CNA's missing visits will be hard on your reputation, start doing spot checks, call a few pt's several times each week to make sure things are going ok. Ask them how their visits are, if the staff is on time, how long they stay.... Although some people may not call you, if you call them they will let you know of any complaints. If your staff knows you are spot checking (announce it loud and clear) it helps discourage that. We also have a zero policy for no calls/ no shows. It's pt abandonment and can result in immediate dismissal.

Also pay your CNA's the best you can afford. They are overhead in a Medicare agency, but with prudent Frequency and duration they can be compensated decently. Many of our referrals come from our CNA's (we give them movie tickets for any referrals that are admitted). We also have a career latter. We have CNA's that assigned to more complex diagnosis, that can be trainers, some that do private duty (for a lesser rate) and medicare clients for the higher rate.

Sorry so long winded. If you need I can post our DON job description.

ea.bednar · Feb 18, 2011

no THANK you for lots of feedback! It is really helpful. I have a DON job description! I have read it. It's helped me put things into perspective, but I'm still trying to figure out HOW to lead, look at things through a leadership perspective.

The administer that I work for has also been a "consultant" for the company. She knows her stuff! This week she has been trying to teach me how to lead using the "sink or swim" method. I know WHY she is doing it, but I'm not sure how I should react to this method. Before she TOLD me every thing I asked her, and now she's trying to get me to figure it out myself, but it's exhausting and has causes kind of an emotional reaction because I still don't know how.

She told me that she would be finished working for the company when the CEO and myself knew how to do our jobs, and then the CEO would also be the administrator, and the company would hire some one to do the billing. Is this common practice? She has planned and lead a successful HHA in the past, and she also gets HHA out of failure.

Thanks for the aide tips. This was very good advice. Is you have any more insights I would greatly appreciate it! Sorry I don't have any more specific requests. I really want to learn anything/everything I can!

ea.bednar · Feb 18, 2011

Also the CEO is in charge of HR, though I am hiring aides independently. And I am not responsible for any billing/medical coding, and the agency is planing on having a expert one on staff, though I need to learn the basics (I have some coding books.)

tewdles, RN · Feb 18, 2011

I have no idea of your background so I cannot know what you need to know...

but my recommendation would be for you to be bold while she has your back. Now is the time to learn as much as you can about running this business, while she is directly mentoring you, so that you can learn from but not be devastated by your mistakes.

Good luck!

HeySis, BSN, RN · Feb 18, 2011

We have done our own coding in the past, but let me tell you, coding for HH is a specialized area and even just knowing how to code is not enough. As coding effects your reimbursement either get someone that has been trained to code for HH or hire it out. We had two different companies sign HIPPA agreements and code several charts each (they did this for free, then wrote a summary of the service and how it would help us.) and then compared the two companies (we had them do the same charts and got different, similar, but different answers) and chose one. The company also reviews the H&P, OASIS, and therapies evals and will give OASIS recommendations. This is something you should be doing as the DON to teach/train your staff on OASIS. BUt if you don't know how this service is valuable. It is always the clinicians decision if their answers make sense and the OASIS should be changed. The turn around time for the coding and review is 24 hours. Time is important in HH because of deadlines.

We have also hired a billing company, this I have mixed feelings on. They check eligibility and do billing for the medicare side of things but not the private duty. We have learned a lot from having them do this, but as I always had to know what was coming in and such it seemed I was double checking everything anyway. There was value in the beginning but I think we will take it back over here soon as it doesn't seem to be saving us time or money now that we have some processes in place.

Also if your consultant/administrator has been helpful I would make sure you have a contract will her that allows you to call her and find out how to do things as new situations appear. Keep her on tap, over time you find yourself using her less and less, but resources are always good to have.

KateRN1 · Feb 21, 2011

It sounds like the agency is trying to become Medicare certified. If not, then none of the follow-up questions apply so read no further. Do you have any experience as a home health nurse in a Medicare certified agency? Are you familiar with the OASIS assessment tool and how it drives reimbursement? Do you know what HHRG and HIPPS are? Do you know what makes a visit skillable and billable? Do you know what RAC auditors are looking for and how they can destroy your agency? Do you know what the therapy thresholds are and how to keep therapists in line? Do you know where the line is to turn a profit vs. break even? Is your nursing background varied enough that you can serve as a mentor to the nurses who come to you? Do you have the experience to tell a nurse or a therapist why something has to be done a certain way?

Home health is a very heavily regulated industry with the strings getting tighter every year. Knowledge of the rules and regulations, along with the ability to be a resource person for your skilled staff is 90% of the battle, and those both come with years of experience. The ability to lead is a whole 'nother ball of wax.

If this is a Medicare agency, I have to wonder why on earth someone with no experience in home care would be hired as a director of nursing. Or why that person with no experience would accept the position. Would you accept a position as the nursing supervisor of a post-anesthesia care unit if you had no PACU or OR experience? Or a pediatric unit without any peds experience? And what would you think of the person who hired you?

I know it seems like they're trying to be nice to you and give you all the things they think you need to succeed, but the reality is that the thing you need most is experience and they are not in a position to give it to you. Sorry to be harsh, but there it is.

If however, you do have zillions of years of homecare experience, just not with this agency, and you do know about all I mentioned in paragraph 1, then welcome aboard--it's a bumpy ride, but always exciting!

The aide thing--that's always tough. Ask your nurses for good candidates. Also try your local tech-training places that do the home health aide/CNA training. If they have a career day, that's a good place to start, or let the placement manager know that you are hiring. Treat them decently, pay them well, appreciate them, provide for their continuing education, involve them in patient care decisions whenever possible.