So I am taking a graduate level research class, and my textbook keeps talking about how there are all of these great care models shown to improve outcomes for patients that aren't being utilized in practice. I just keep thinking about how nurses NEVER have ANY time, and this is probably contributing greatly to the lack of research in practice. It seems like the problem is getting worse and in some cases practice is not only not evidence-based, it's not even safe. Then good nurses stop being nurses because expectations are impossible.
I guess I'm wondering if anyone has any ideas on how to improve staffing ratios? There is evidence out there that the role of the nurse as an educator is as important. How do nurses get the time they need to serve as effective clinicians?
I've read other posts with suggestions like, "cut the CEOs salary", which is a nice idea, but not likely to happen without some sort of catalyst. Does anyone know what the catalyst could be?
The first step is to get involved in councils or committees in the workplace. Then you can make connections with higher-ups and perhaps speak with more authority and clout to them about needs you see on your unit. The bottom line however, is . . . the bottom line. Each organization and those that run it have the right to budget as they see fit. Some are more motivated than others to turn a profit vs. provide excellent care.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
Well, I admitted it was just a gut feeling. I guess I just find the idea of a patient (or insurance company) being billed for each individual care rendered to be sleazy? I'm not a huge fan of PT or lab billing every time they walk in the room, either.
Nurses wouldn't have to bill for each task or skill preformed. I used to have a of taking care of pediatric vent patients in their home. We billed the state directly for our services. W simply billed for the hours, not skills or tasks preformed. The rate was based on patient acuity.
This discussion is enjoyable, but is somewhat surreal. No matter what, we would still have to work for a company somewhere. A private company would not pay me my $30+ hourly wage plus benefits if they didn't need to. With the surplus we are expected to have, we would be paid $16 an hour max. Plus we would see 20+ patients per day easily. But all of this is a moot point. The hospital is where bedside nurses belong and they should be employees of the hospital. The answer is to organize, march, and fight for better staffing and quit making it all about money. We would get the country on our side with the staffing issue, however, nobody will feel sorry for a $60/hour California nurse who thinks that they should get a bigger slice of the pie.
I think it would be difficult to bill for nursing services because we do so many varied things for out patients that it would be hard to put an amount for each and every thing we do. Maybe if the patient needs a lot of nursing care than a higher amount could be billed. Than again, the patient who is seen as pretty independent can take a lot of time as well because of other issues such as they may be anxious, etc.
From my understanding (at least in LTC) each resident is assigned a RUG score based on data gathered in the MDS. (This is referring to Medicare/Medicaid patients.) The RUG score determines the rate of pay per day per resident. Example: Mr. Smith is a Medicare rehab patient so his RUG rate will be higher, in the hundreds of dollars per day. The facility is paid that rate per day for his care. All expenses, including meds, meals, room, treatments, labs, etc. must be taken out of that daily dollar amount. Example #2: Mrs. Jones is a LTC resident on Medicaid. She is fairly functional, only requiring occasional asst but otherwise independent. Her RUG level could easily be less than $100/day for all care provided including room, meals, etc. However, Medicaid will pay for meds, tx's, labs, etc. If you add up the dollar amount of care provided, including the hourly wage of her nurse and CNA X 24hr/day, meals, housekeeping, etc, the facility is likely losing money on her and others like her.
In conclusion, all monies paid by Medicare/Medicaid are the one honeypot that every discipline in a facility is dipping their hands into. There is usually not much money left, if any at all to justify or afford to increase staffing ratios. The idea is nice, but the way the payment system is set up there is no room for more staff. The insurance companies and CMS (Centers for Medicare & Medicaid Services) have us in a financial choke-hold. The only "fix" that I can see is to change the payment system itself. That would entail fighting with the U.S. Government and insurance companies. No small tasks there.
From my understanding (at least in LTC) each resident is assigned a RUG score based on data gathered in the MDS. (This is referring to Medicare/Medicaid patients.) The RUG score determines the rate of pay per day per resident. Example: Mr. Smith is a Medicare rehab patient so his RUG rate will be higher, in the hundreds of dollars per day. The facility is paid that rate per day for his care. All expenses, including meds, meals, room, treatments, labs, etc. must be taken out of that daily dollar amount. Example #2: Mrs. Jones is a LTC resident on Medicaid. She is fairly functional, only requiring occasional asst but otherwise independent. Her RUG level could easily be less than $100/day for all care provided including room, meals, etc. However, Medicaid will pay for meds, tx's, labs, etc. If you add up the dollar amount of care provided, including the hourly wage of her nurse and CNA X 24hr/day, meals, housekeeping, etc, the facility is likely losing money on her and others like her.
In conclusion, all monies paid by Medicare/Medicaid are the one honeypot that every discipline in a facility is dipping their hands into. There is usually not much money left, if any at all to justify or afford to increase staffing ratios. The idea is nice, but the way the payment system is set up there is no room for more staff. The insurance companies and CMS (Centers for Medicare & Medicaid Services) have us in a financial choke-hold. The only "fix" that I can see is to change the payment system itself. That would entail fighting with the U.S. Government and insurance companies. No small tasks there.
This is my understanding as well. Evidenced not just in LTC/LTAC's, but also Home Care, and other branches.
The first step is to get involved in councils or committees in the workplace. Then you can make connections with higher-ups and perhaps speak with more authority and clout to them about needs you see on your unit. The bottom line however, is . . . the bottom line. Each organization and those that run it have the right to budget as they see fit. Some are more motivated than others to turn a profit vs. provide excellent care.
And there are countless committees that make excellent suggestions that are vetoed by those in administration. Most all of the committee work nurses do are illusions. It gives the sense that changes are being made, when in fact, nothing changes.
For example, local surveys that I was aware of, pointed to over 90% of all staff nurses felt that some units could explore team nursing, per what a particular nurse is skilled in. An entire concept map was done. There was a lot of work put into making this work. The DON stopped it in its tracks, as "that's not how it is done" and other vague issues that made no sense. Said committee never had another meeting.
So if we continue to have top heavy facilities that rarely take into account the needs of nurses to do their job well, within the confines of a customer oriented approach, and hit each "meaningful use" and "we want you to be delighted" situations--let nurse's govern themselves, let's practice it, mean it....all those things that are not happening now.
Let NP's be mid-level practitioners, which are billable items, and let nursing skill be reimbursed by skilled care. But in order to give skilled care, the ratios need to be raised to the level of functioning. It seems like it is a private duty world they are attempting to sell--but are only willing to pay for express care nursing.
Home care gets a bundle or a preset amount for the episode of care for each patient based on the DRG and needs determined in the start of care. So the agency gets x amount of dollars to do all of the care for the patient during the care period.
anon456, BSN, RN
3 Articles; 1,144 Posts
The first step is to get involved in councils or committees in the workplace. Then you can make connections with higher-ups and perhaps speak with more authority and clout to them about needs you see on your unit. The bottom line however, is . . . the bottom line. Each organization and those that run it have the right to budget as they see fit. Some are more motivated than others to turn a profit vs. provide excellent care.