- Email: [email protected]
Essential Program Components for Perinatal Home Care
C L I N I C A L ISSUES
Essential Program Componentsfor Perinatal Home Care Linda Goodwin, RNC, MEd
Home care will continue to be a rapidly expanding area of health care. This growth will be evident in the perinatal nursing specialty. There are multiple models for delivery of perinatal home services. In each case, consideration needs to be given to licensing and other standards; to operational areas such as staffing, supplies, equipment, and reimbursement; and to quality issues, such as staff development, internal and external customer service, and a continuous quality improvement program. Successful marketing of the services requires recognition that the product is nursing care.
decreased stress placed o n the family system when a woman o r newborn is able to remain at home, rather than b e separated from the family support system by hospitalization (DeVore, 1990). The current mandate for health-care reform in the United States presents perinatal home care with an unprecedented opportunity. Health-care reform identifies home care as a cost-effective alternative to hospitalization and proposes full payment or 80% insurance coverage for all individuals. This national mandate also would eliminate the freedom for payers to establish widely varying contracts and policies that often exclude new, innovative services or those provided by nurses and other nonphysician care providers, although these alternatives are costeffective.
The Role of Home Care in Perinatal Nursing Models fo r Home-Care Programs
1990s is related to increased federal Medicaid and Medicare reimbursement, recognition of cost benefits, increased availability of services, advances in technology, and consumer (i.e., patient) preference for h o m e care as an alternative to hospital admission (Humphrey, 1988). The trend for expansion of h o m e care has been evident in the perinatal nursing area. Services spanning the trimesters of pregnancy and the postpartum-newborn period have developed and grown. Programs that facilitate early postpartum discharge of mothers a n d neonates have not only successfully demonstrated cost savings a n d improved outcome, but also have shown that the educational and support needs of n e w families can best b e satisfied by nurses in the home setting (Evans, 1991). Hospital costs are the most critical element of healthcare costs. I n perinatal care this is particularly evident with long-term antepartum o r neonatal hospitalization. When home care shortens o r substitutes for acute care hospitalization, the cost benefit is uncontested (Rogatz, 1987). Less quantifiable, but of equal importance, is the
October 1994
Hospital-BasedPrograms Hospital-based programs for perinatal home care are increasing as a result of hospitals’ recognition of revenue potential, case managers’ focus o n cost benefits and continuity of care, and the preference of physicians and other care providers to have home services by nurses they know and trust. In addition, hospitals have an existing pool of trained manpower to provide the services. Home-care services are different from acute inpatient services in many ways; thus, success of a hospital-based program is enhanced when the program is a separate cost center with knowledgeable home-care management and dedicated budget, staff, and other resources needed to support the program. Leadership by individuals who are experienced in home care and committed to the success of the hospital-based program will enable experienced perinatal nurses to make a successful transition to this n e w role a n d to ensure agency compliance with regulatory standards and the program’s fiscal well-being. Entrepreneurial Programs Entrepreneurial nurses have recognized the opportunity created by the growth of h o m e health care and have
J O G N N 667
CLINICAL ISSUES
launched new careers as small-business owners. Nurses who accept this challenge face long hours, hard work, and other sobering realities of the business world, but job satisfaction is substantial, and financial success can be achieved if there is prudent business management. An uninformed approach to establishing a nurse-owned small business in perinatal home care is not recommended; this can result in financial misfortune or entanglement in unrecognized regulatory red tape that can lead to unwelcome litigation. The knowledge and skills needed for becoming a business owner can be gained by reading, working with a consultant, attending college or private courses and seminars, and by working in an existing successful business. State regulations may dictate that the nurse have special credentials and licensure to qualify for reimbursement. When state nurse practice acts allow and payer regulations permit, nurses owning their own perinatal homecare business may contract with hospital or physicians to provide specific services, such as nonstress tests or home bilirubin therapy, or services for a specified group of clients. They also may market themselves to payers or providers and generate referral business. If nurse business owners can convince case managers that their model of care provides cost savings and greater continuity of care, appropriate referrals may result. Home-Care Agencies Perinatal home care has developed by expanding programs within agencies already providing a variety of comprehensive home health services, such as infusion therapy, rehabilitation, and hospice care. Other home-care agency models provide services focused solely o n women’s, perinatal, and children’s needs. Most home health-care agencies are for-profit; the agency exists to achieve a positive bottom line. The mission statement will reflect the importance of quality care and meeting the needs of patients and families; the statement also will define the agency goal of long-term financial viability. It is imperative that nurses working for an agency be aware of the success indicators established by the employer and that they b e cognizant of the value placed on reaching the financial, as well as the service and clinical, goals of the company. Nurses who provide perinatal home care, as employees of a home-care agency may be salaried or be paid o n a per-visit basis. In either case, time is money, and nurses who have practiced in not-for-profitsettings initially may feel challenged and pressured by the daily realities of this model of care, with its competitive marketing, focus on profit, and definition of their services as a “product” provided by the company. I t is important for nurses to accept the economic reality that this product must be paid for because the agency will not be able to continue to e m ploy,the nurse to provide the care if the services are not compensated.
services through government-funded programs, which usually exist to provide services the government thinks will not otherwise be provided. Government payments to providers are limited to specific services for identified groups of individuals. In the United States, the federal government pays for approximately 30% of health care, and state and local governments pay about 10% of all health-care costs (Finkler 5z Kovner, 1993). Perinatal home-care services have not appeared to be a priority for government-funded programs, despite the documented cost benefits. The governmental prospective payment system of Diagnostic Related Groups (DRGs) classifies patients according to the principal diagnosis and the amount of care required; payment for each patient in the DRG is the same predetermined amount, regardless of the costs for treatment incurred by the provider. If the hospital stay costs the hospital more than the DRG amount, the hospital loses the difference. The converse occurs if costs of the stay are less than the DRG rate; the hospital realizes a profit. Under the DRG system, discharging a long-term antepartum patient from the hospital and incurring the additional costs of home care is not fiscally attractive to governmental agencies. The DRG system originally applied only to Medicare patients; however, some states have adopted the system for Medicaid payments, and a few states have a similar system that applies to all payers. In short, DRGs are becoming the dominant force in determining payment for health-care services. DRGs are being developed for outpatient and ambulatory care; this may open the door for home care as an alternative to hospitalization, particularly for patients who receive care through governmental agencies (Finkler 5z Kovner, 1993).
Operational Issues StaJing There is no question that personnel cost is the single greatest contributor to health-care costs. This factor requires careful consideration in planning and managing a perinatal home-care program. The availability of qualified, competent personnel may dictate the program’s recruitment and retention policies and influence decisions about benefits to be offered in the compensation package. It is evident that the success of a health-care organization is dependent on having a nurturing and supportive staff attitude toward patients; quality of staff interaction with patients is key to successful marketing efforts. A recent study of patient satisfaction indicated that the three top success indicators all related to the patients’ perception of how they were treated by the nurse (Finkler & Kovner, 1993).
Government-Funded Programs All levels of government are providers of health-care services, e.g.,military and veterans’ hospitals, and payers for
Salaries. Salaries and benefits represent the single largest cost in the operational budget; this item should not exceed 60% of gross revenue (Finkler & Kovner, 1993). Wages and benefits should be competitive with other employers in the area. This information can be obtained by a market survey. Fringe benefits are costs of em-
668 J 0 G
Volume 23. Number 8
:V N
Home Care
ployees in addition to their salary and typically include Social Security taxes, health and life insurance, and other employee taxes and benefits. Each organization will calculate a benefit rate, but these rates commonly range from 22% to 23% of gross salary. Hiring. Staff turnover is expensive; one study estimated the mean turnover cost per registered nurse at $10,198 (Finkler 8r Kovner, 1993). Managers of perinatal homecare programs are wise to seek and retain personnel who offer a balance of perinatal knowledge, skill, and sensitivity to client needs. Taking time to d o careful interviewing and reference checks is essential to the creation of a successful team. Information available through reference checks with previous employers can be limited because of current human resources policy. Often the only information released is dates of employment and eligibility for rehire. Offering applicants an opportunity to observe or accompany a current employee doing the actual job may provide additional information about the individual’s potential for success in the new role. Involving staff in the interview process also can be effective in screening for individuals who will be successful in perinatal home care. In any situation in which staff members express reluctance to support hiring of an applicant, the responsible manager is well advised to take additional time to interview and evaluate the individual. Home care is unique; not all nurses will make a successful transition from other areas of health care. Patients referred for perinatal home-care services usually will have significant risks and complications. In the home, the nurse will not have the access to consultation and collaboration with peers and other care providers that is available in the acute care setting. Independence in clinical assessment and judgment are required. Hospital acute care experience usually provides the best background for this added responsibility. Scheduling. Home-care nurses generally can be expected to spend one-third of their working hours in travel, one-third in providing care, and one-third in documentation. Because the patient visit is the only reimbursable portion of this time, scheduling and organization of patient-care activities is essential for financial success of the program. Nurses will need to consider planning the most efficient routes for travel to avoid heavy traffic times and locations; planning visits by geographic proximity; organizing supplies, chart forms, and other required paperwork, such as billing forms and expense reports; ensuring that patients will be at home and prepared for the visit; and setting realistic expectations by patients for the length and purpose of each visit. As in the acute care obstetric setting, the home-care census will fluctuate unpredictably. New referrals usually need to be seen within 24 hours and often sooner. This presents a challenge for scheduling of staff and visits. The home-care supervisor must demonstrate the creativity and flexibility to accommodate all of these demands. For example, nurses can be offered an incentive, such as a
Ocloher 1994
bonus or paid time off, if they meet or exceed a daily or weeklyvisit expectation and provide timely, complete records for billing. Home-care services require around-the-clock availability of nursing staff. At least 1.4 full-time employee equivalents must be hired to provide 7-day per week coverage, with additional employees needed to cover nonproductive time (sick, vacation, holiday, and other paid nonworked hours, such as orientation and in-service time). Nonproductive time can be expected to equal approximately 15% of worked hours; this percentage will vary with tenure and benefits, and can be calculated for a specific staff based o n historical data and known benefits. Unless these nonproductive hours are budgeted and coverage is planned, undesirable and costly overtime salary expense will be incurred. In addition, staff likely will begin to feel overworked and frustrated; poor performance and errors in care or documentation will follow, and resultant staff turnover will be excessive and costly. Orientation and training. A comprehensive, organized orientation and training program will prepare nurses to practice effectively and safely in the home. In addition to adapting perinatal clinical knowledge and skills to this new practice environment, the nurse will need time to master the unique skills for providing care in the home. Documentation of this training, including skill checklists and outlines of class content, will be reviewed in some detail during licensure o r certification visits. Annual recertification and documentation of competency for all staff will be expected. In addition to the benefits of compliance with regulatory requirements, a good orientation and training program promotes job satisfaction. Nurses’ ability to know and perform their responsibilities is promoted by a program in which required knowledge and skills are reviewed and validated during orientation and at least annually thereafter. An example of a content outline for orientation to perinatal home care is shown in Table 1. Equipment Perinatal home care goes beyond the range of usual home-care services provided; the diagnoses are more acute and require greater nursing clinical judgment and technical skill. The equipment requirements for this high level of care represent a significant financial commitment. Several models of equipment may be required for one type of service. For example, monitoring of preterm uterine activity may be done best by a monitor with guard-ring technology, whereas maternal-fetal surveillance requires a state of-the-art electronic fetal monitor; intravenous hydration for hyperemesis gravidarum requires different pump capabilities than does the subcutaneous infusion of tocolytic medication for preterm labor. It is important to determine whether equipment will be needed daily, weekly, or only occasionally and compare costs of purchase, lease, and rental of such equipment. When evaluating the cost of purchasing or leasing compared with renting, hidden costs such as storage,
J 0 CN N
669
C L I N I C A L
I S S L ’ E S
Table 1 . Content Outlinefor Orientation to Home Care
agencies, sharing or contracting for clerical services and equipment maintenance may be the best option.
I . Assessment
A. Physical
B. Psychosocial C . Home environment D. Risk identification 111.
Documentation A. Clinical
B. Reimbursement/billing/expenses IV. Equipment and supplies A. Use and safety
B. Maintenance V. Standards A. OSHA, JCAHO B. Professional/licensure
C. Organizational VI. Operations A. Organizational structure
B. Scheduling C. Human resource policy and
procedure 1. Performance management program 2 . Job responsibilities/expectations D. Payroll VII. Home care as a business A. Marketing and sales B. Budget/revenue/expense VIII. Quality improvement A. Internal and external customers B. Customer service C. CQI program
transport, supplies and disposables, repair, maintenance, cleaning, and updating should be considered. Backup equipment is necessary any time a patient service or therapy is dependent on properly functioning equipment. Regular equipment maintenance must be documented; certification for accuracy and safety before each patient’s use is required for some types of equipment, such as infusion pumps. These records usually are reviewed in some detail during any site visit for licensure or certification. If the personnel in the agencydo not have the skills or capability to perform this ongoing maintenance and testing, it may b e prudent to contract with a clinical engineer from a hospital or other agency for these services. The home-care agency will need computer equipment to process documentation, insurance claims, and financial data and a variety of additional office equipment. Maintenance agreements must be considered for support of most leased or purchased equipment. For smaller
670 J O G N N
Supplies
Supply sources and delivery schedules must be established so that items needed for patient care and other essential clerical and maintenance functions will be readily available. Most vendors are eager to assist with selection of items, establishing par levels, and arranging for delivery on an on-call-as-neededor regular basis. I t is wise to explore all alternatives and negotiate for the best deal among the vendors for similar products; prices are rarely fixed. In addition, expect excellent service and d o not hesitate to change vendors if service or price is not satisfactory. There are economies of scale in participating in larger volume purchasing contracts if these can be negotiated in cooperation with other programs or agencies. If a purchasing contract is considered, ensure that terms and conditions will make the contract void should service or product quality become unsatisfactory. Realistic par levels should be established and adjusted as indicated by experience and volume. Keeping stock at the minimum levels for efficiency and safety will help to control cost; patient charge items on the shelf in the office are “riding” on the program’s budget until those items are charged, billed, and reimbursed. It is more prudent to have those items on the vendor’s shelf and delivered to the agency as needed. An indjvidual in a support role should be responsible for regular ordering, stocking, and monitoring of supplies so that the persons providing direct care can depend on having the items they need. Give this individual responsibility and authority to manage this supply function; set high expectations for job performance and reward good results. Unnecessary time spent by nurses attempting to find, borrow, or substitute for a necessary item or rearranging visits because an item is unavailable is frustrating for the nursing staff and wasteful of the program’s most valuable resource. Remember: time is money. Billing and Reimbursement
The reimbursement function is specialized and requires a person who is knowledgeable about the business of perinatal home care and the payers. Each payer will have rules, exceptions, exclusions, and qualifiers for reimbursement. The reimbursement person has to know the rules, recognize that they may vary significantly among payers, and may change without advance notice. Before a patient is admitted for services, it is essential to ascertain the potential for reimbursement for the specific services by the specific payer based on the patient’s specific diagnosis and risk factors. Initiating services before insurance authorization (termed “clearing the patient”) may place the provider at risk for nonpayment, even if the services are subsequently authorized. Even an expert in reimbursement may spend several hours on the telephone attempting to clear one patient for services. It is wise to
Volume 23: Number 8
Home Care
hire the most qualified individual(s) for this responsibility, provide the necessary tools to do the job, and expect excellent results. Reimbursement for supplies and services is dependent on the billing process. If a supply item or visit is not charged, it cannot be billed; if it is not billed, it will never be reimbursed, and the agency will have to cover the cost out of its margin. This is not a complex concept; however, staff members who provide care and use supplies often are reluctant to accept this reality. The manager will be challenged to hold staff members accountable for completion of paperwork in a timely manner. It will be helpful to set firm expectations during staff orientation and to provide consequences for noncompliance with paperwork. The manager can assist by making certain the paperwork system is functional and efficient. Use of laptop computers for documentation in the field can be effective for clinical and reimbursement purposes. Billing and reimbursement efforts must be successful, or the business will not prosper, and all the employees will experience the negative results. Liability Insurance Liability insurance is not optional; a policy must be in place. If a program is associated with a hospital or agency, the existing coverage usually is sufficient. A nurse-owned small business will need to seek the appropriate coverage and ensure the adequacy of coverage from the professional and the business perspective. If an agency or program wishes to contract or associate with a hospital or other agency, proof of liability coverage usually is required. Nurses who work in home health-care programs may wish to examine the details of the agency’s liability insurance policy to ensure the adequacy of coverage for themselves as employees. Because home health care is more diverse than acute inpatient care, nurses may be performing broader functions with less supervision, and the language of the policy must address those issues. In addition, job descriptions for the nurses must clearly delineate responsibilities so that “scope of practice” is agreed upon by employee, supervisor, and patient. In the home, nurses will find themselves in many situations in which the patient or family may request assistance or services not included in the physician prescription and beyond defined nursing responsibility. The nurse must recognize these limits and be familiar with other resources to which she can refer clients.
Standards, Licensure, and Regulatory Issues Standards Standards are models and guidelines for practice established by agencies or organizations at local, state, or federal levels. Regardless of local practices, nurses are held to established national standards. Agency standards. Each agency will be required to have policies, procedures, and protocols to define and guide all elements of care the agency states that it offers. These
October 1994
standards must comply with established national standards; when policies necessarily deviate from standards because of the uniqueness of home care o r a particular population, a statement such as the following is suggested for the policy and procedure manual: We recognize the established standards of care for (condition or situation) call for (prevailing standard). We also recognize that there are inherent differences in providing this service in the home (or for this population). Under these circumstances, and for the specific reasons stated herein, we have adopted the following policy (or procedure). . . Manuals containing the agency’s statements of standards must be kept current and accessible to staff. During orientation, all employees who will be held to these standards must be provided with the time and opportunity to become familiar with the content of these documents. Annual review and awareness of additions and revisions should be required and ensured by managers. Organizational standards. One of the primary responsibilities of professional organizations is to create and define standards of care. For perinatal services, the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) is recognized as the national professional organization. AWHONN publishes competency statements, position papers, and practice guidelines. The NAACOG Standardsfor the Nursing Care of Women and Newborns (1991) provides written statements regarding scope of services, and policies, procedures, and protocols for antepartum and intrapartum home-care nursing practice. Standards set by other professional organizations, such as the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, and the American Hospital Association may influence standards for perinatal nurses. Legal standards. Legislated standards in addition to those addressing licensure will affect the home-care agency’s practices and conduct of business. Occupational Safety and Health Administration (OSHA) regulations, employment standards such as wage/hour and equal opportunity laws, and taxation laws are examples of these additional standards. Payer standards. Insurance companies and other payers may establish standards for care required for reimbursement of authorized services. The home-care agency must be able to demonstrate through documentation that the standards are met, or payment of claims may be denied. Licensure Licensure is a mandate by a regulating body. Professionals are required to be licensed to practice within their specialty (i.e., registered nurse; home health-care agencies must be licensed to provide care in most states; businesses are licensed to operate within a municipality). Licensing requirements vary from state to state and within
J O C N N
671
C L I .b I C A L
I S S I‘ E S
local jurisdictions. State licensure regulations can be determined by contacting the state’s Departments of Health or Licensing. Unique programs such as perinatal services may find that it is difficult and confusing to adapt existing regulations to the specialty services of perinatal h o m e care. Extensive dialogue between the home-care providers and the regulatory agency may b e needed to complete the licensure process. Certijcation Certification usually is a voluntary process. For example, perinatal nurses may choose to be certified in their specialty by an organization such as the National Certification Corporation. Provider organizations may elect to b e certified by the Joint Commission for Accreditation of Healthcare Organizations (JCAHO). Although JCAHO certification is considered voluntary, there are implications for reimbursement and contracting with third-party payers when the agency is not certified. O n J u n e 1, 1988, JCAHO added standards for durable medical equipment, infusion therapy, pharmacy, and coordination of care among providers. Only hospitals are held to these standards at this time; however, third-party payers are identifying a need for national standards for all services and may adopt those set by JCAHO (WillHome Care Re Round bji.JCAHOStavzdards?, 1988).
Continuous Quality Improvement Programs addressing quality issues have been evident in health care for some time. The earlier focus o n retrospective review and identification of problems has given way to concurrent review and programs for continuous quality improvement (CQI). All employees of a n organization are expected to participate actively in the CQI program. Clinical CQI The licensed or certified home-care agency will b e required to demonstrate an active C Q I program. All e m ployees are expected t o b e familiar with the program and able to articulate the process during scheduled and unannounced site visits f o r accreditation or licensure. The challenge for facilitators of the CQI program is to make it a useful tool for demonstrating success and determining the focus for changes and adjustments in current practice. Outcome information from CQI monitors should b e the basis for changes in policies and procedures and for e d u cational and in-service efforts. O n c e an employee has experienced a positive, useful outcome from the CQI process, h e or she will b e much more likely to b e an active, compliant participant in the program.
hospitals, clinics, and other referral sources. Internal customers include colleagues and peers; other departments, such as billing and purchasing; support personnel, such as clerical and maintenance; and managers. Successful organizations strive for continued excellence in internal a n d external customer service. The organization’s image is created from within and begins with the attitude and actions of each individual. When respect and courtesy are extended to every internal customer with the same e n thusiasm and commitment often reserved for external customers, results are overwhelmingly positive. External customers are the source of the business. Agencies that have not offered perinatal services in the past are creating n e w divisions and services to market, and this area of h o m e health care has become extremely competitive. If a n agency does not take good care of its customers, someone else will. Service excellence in this business means “doing it right” every time. This attitude is epitomized in a comment from a n astute home-care nurse. She stated, “The patient is always right; even when patient is not right, my agency and I will make it right for the patient.” CQI monitors of internal a n d external customer service are revealing and rewarding. When the organization and individuals are providing good service, CQI outcomes are visible acknowledgment. When CQI monitors demonstrate problems in performance or customer service, the data that have been obtained clearly define the focus for training a n d counseling that can correct t h e deficiencies.
Marketing Perinatal Home Care m a t Is the Product? The product provided by perinatal home-care services is nursing care. Equipment, supplies, and drugs are billable components of the h o m e care, but the unique and valuable commodity being marketed by the agency is the knowledge, skill, sensitivity, support, and hands-on care delivered by the nurse in the home.
Custpmer Service and CQI For any organization, the customer is defined as any individual or group receiving the services of another individual or group. Customers may b e “external” or “internal.” Examples of a home-care agency’s external customers are patients, families, physicians, insurance case managers,
Home Care:A Relationship Business Home care is a relationship business; referrals and business growth are achieved as a result of establishing positive relationships with internal and external customers. The prudent manager recruits individuals with exceptional “people skills” and existing networks with perinatal health-care providers and payers. Marketing a service is different from marketing equipment or pharmaceuticals; techniques that bring positive results in selling birth control pills or birthing beds may not b e effective for marketing services. It is not possible to provide free samples or bring in a model for trial. Without input and training from the agency’s nursing staff, it will be‘difficult for the sales and marketing staff to gain the full understanding of the product and the customers that will lead to successful sales and marketing efforts. The people component is the key to presenting this
672 / O G A ’ h ’
Volume 23. Number 8
Home Care
product. Establishing the relationship takes time; the approach must be tailored to the individual or group; trust must be established; consistency, reliability, and dependability are building blocks for this relationship. Once the relationship is established, it must be nurtured and maintained for continued success. The competition will be at the door; a large customer referral source will be the prime target for every other agency seeking to provide the same product.
Marketing in the Managed Care Environment Managed care is a system in which an individual, such as a nurse case manager, determines what is necessary for the patient and authorizes the care and services (Finkler Lk Kovner, 1993). The case manager is an intermediary between the provider of services and the patient. The goal of managed care is to decrease the costs of health care by identifying and authorizing only those services deemed to be “necessary.” Case management may eliminate some services but also can ensure that patients receive appropriate and timely care. Case managers are significant external customers; marketing the perinatal home-care services to these individuals will become increasingly important as their role expands throughout the industry. Case managers will drive and direct care for most, if not all, potential perinatal and neonatal patients. These individuals should be at the top of the priority list for relationship development if the perinatal home-care service is to survive and thrive in this tapidly changing health-care environment.
zons by bringing their expertise and skills to home care. The experience will challenge the nurse by tapping areas of nursing assessment and intervention that extend beyond the scope encountered in the hospital or clinic. Home care has multiple models for care. Operational issues, standards, and assessments of quality have some common ground in all health-care environments; however, the arena of home care has unique attributes that must be understood and appreciated for successful development, marketing, and delivery of services.
References DeVore, N. (1990). Maternal psycho social adaptations to high risk pregnancy. In K. A. Buckley & N. A. Kulb (Eds.), High risk maternity nursing (pp. 15-19). Baltimore: Williams & Wilkins. Evans, C. (1991). Description of a home follow-upprogram for childbearingfamilies.JOGNN, 20, 113-118. Finkler, S., & Kovner, C. (1993). Financial management for nurse managers a n d executives. Philadelphia: WB Saunders. Humphrey,C. J. (1988).The home as a setting for care. Nursing Clinics ofNorth America, 23,305-314. NAACOG. (1991). NAACOG standards for the nursing care of women a n d newborns (4th ed.).Washington, DC: Author. Rogatz, P. (1987). Perspective on home care. Public Health Nursing, 4, 7-8. Will home care be bound by JCAHO standards? (1988). Hospitals, G2,57.
Conclusion
Address for correspondence: Linda Goodwin, RNC, MEd, Labor and Delivery, Sentara Norfolk General Hospital, 600 Gresham Drive, Norfolk, VA 23507.
Home care will continue to expand in the specialty of women’s and children’s services. This offers an excellent opportunity for experienced nurses to expand their hori-
Linda Goodwtn is the nurse manager tn the Labor and Delivery Department of the WomenS Health Pavilton, Sentara Norfolk General Hospttal, Norfolk, VA.
October 1994
J O G N N 673
Essential Program Componentsfor Perinatal Home Care Linda Goodwin, RNC, MEd
Home care will continue to be a rapidly expanding area of health care. This growth will be evident in the perinatal nursing specialty. There are multiple models for delivery of perinatal home services. In each case, consideration needs to be given to licensing and other standards; to operational areas such as staffing, supplies, equipment, and reimbursement; and to quality issues, such as staff development, internal and external customer service, and a continuous quality improvement program. Successful marketing of the services requires recognition that the product is nursing care.
decreased stress placed o n the family system when a woman o r newborn is able to remain at home, rather than b e separated from the family support system by hospitalization (DeVore, 1990). The current mandate for health-care reform in the United States presents perinatal home care with an unprecedented opportunity. Health-care reform identifies home care as a cost-effective alternative to hospitalization and proposes full payment or 80% insurance coverage for all individuals. This national mandate also would eliminate the freedom for payers to establish widely varying contracts and policies that often exclude new, innovative services or those provided by nurses and other nonphysician care providers, although these alternatives are costeffective.
The Role of Home Care in Perinatal Nursing Models fo r Home-Care Programs
1990s is related to increased federal Medicaid and Medicare reimbursement, recognition of cost benefits, increased availability of services, advances in technology, and consumer (i.e., patient) preference for h o m e care as an alternative to hospital admission (Humphrey, 1988). The trend for expansion of h o m e care has been evident in the perinatal nursing area. Services spanning the trimesters of pregnancy and the postpartum-newborn period have developed and grown. Programs that facilitate early postpartum discharge of mothers a n d neonates have not only successfully demonstrated cost savings a n d improved outcome, but also have shown that the educational and support needs of n e w families can best b e satisfied by nurses in the home setting (Evans, 1991). Hospital costs are the most critical element of healthcare costs. I n perinatal care this is particularly evident with long-term antepartum o r neonatal hospitalization. When home care shortens o r substitutes for acute care hospitalization, the cost benefit is uncontested (Rogatz, 1987). Less quantifiable, but of equal importance, is the
October 1994
Hospital-BasedPrograms Hospital-based programs for perinatal home care are increasing as a result of hospitals’ recognition of revenue potential, case managers’ focus o n cost benefits and continuity of care, and the preference of physicians and other care providers to have home services by nurses they know and trust. In addition, hospitals have an existing pool of trained manpower to provide the services. Home-care services are different from acute inpatient services in many ways; thus, success of a hospital-based program is enhanced when the program is a separate cost center with knowledgeable home-care management and dedicated budget, staff, and other resources needed to support the program. Leadership by individuals who are experienced in home care and committed to the success of the hospital-based program will enable experienced perinatal nurses to make a successful transition to this n e w role a n d to ensure agency compliance with regulatory standards and the program’s fiscal well-being. Entrepreneurial Programs Entrepreneurial nurses have recognized the opportunity created by the growth of h o m e health care and have
J O G N N 667
CLINICAL ISSUES
launched new careers as small-business owners. Nurses who accept this challenge face long hours, hard work, and other sobering realities of the business world, but job satisfaction is substantial, and financial success can be achieved if there is prudent business management. An uninformed approach to establishing a nurse-owned small business in perinatal home care is not recommended; this can result in financial misfortune or entanglement in unrecognized regulatory red tape that can lead to unwelcome litigation. The knowledge and skills needed for becoming a business owner can be gained by reading, working with a consultant, attending college or private courses and seminars, and by working in an existing successful business. State regulations may dictate that the nurse have special credentials and licensure to qualify for reimbursement. When state nurse practice acts allow and payer regulations permit, nurses owning their own perinatal homecare business may contract with hospital or physicians to provide specific services, such as nonstress tests or home bilirubin therapy, or services for a specified group of clients. They also may market themselves to payers or providers and generate referral business. If nurse business owners can convince case managers that their model of care provides cost savings and greater continuity of care, appropriate referrals may result. Home-Care Agencies Perinatal home care has developed by expanding programs within agencies already providing a variety of comprehensive home health services, such as infusion therapy, rehabilitation, and hospice care. Other home-care agency models provide services focused solely o n women’s, perinatal, and children’s needs. Most home health-care agencies are for-profit; the agency exists to achieve a positive bottom line. The mission statement will reflect the importance of quality care and meeting the needs of patients and families; the statement also will define the agency goal of long-term financial viability. It is imperative that nurses working for an agency be aware of the success indicators established by the employer and that they b e cognizant of the value placed on reaching the financial, as well as the service and clinical, goals of the company. Nurses who provide perinatal home care, as employees of a home-care agency may be salaried or be paid o n a per-visit basis. In either case, time is money, and nurses who have practiced in not-for-profitsettings initially may feel challenged and pressured by the daily realities of this model of care, with its competitive marketing, focus on profit, and definition of their services as a “product” provided by the company. I t is important for nurses to accept the economic reality that this product must be paid for because the agency will not be able to continue to e m ploy,the nurse to provide the care if the services are not compensated.
services through government-funded programs, which usually exist to provide services the government thinks will not otherwise be provided. Government payments to providers are limited to specific services for identified groups of individuals. In the United States, the federal government pays for approximately 30% of health care, and state and local governments pay about 10% of all health-care costs (Finkler 5z Kovner, 1993). Perinatal home-care services have not appeared to be a priority for government-funded programs, despite the documented cost benefits. The governmental prospective payment system of Diagnostic Related Groups (DRGs) classifies patients according to the principal diagnosis and the amount of care required; payment for each patient in the DRG is the same predetermined amount, regardless of the costs for treatment incurred by the provider. If the hospital stay costs the hospital more than the DRG amount, the hospital loses the difference. The converse occurs if costs of the stay are less than the DRG rate; the hospital realizes a profit. Under the DRG system, discharging a long-term antepartum patient from the hospital and incurring the additional costs of home care is not fiscally attractive to governmental agencies. The DRG system originally applied only to Medicare patients; however, some states have adopted the system for Medicaid payments, and a few states have a similar system that applies to all payers. In short, DRGs are becoming the dominant force in determining payment for health-care services. DRGs are being developed for outpatient and ambulatory care; this may open the door for home care as an alternative to hospitalization, particularly for patients who receive care through governmental agencies (Finkler 5z Kovner, 1993).
Operational Issues StaJing There is no question that personnel cost is the single greatest contributor to health-care costs. This factor requires careful consideration in planning and managing a perinatal home-care program. The availability of qualified, competent personnel may dictate the program’s recruitment and retention policies and influence decisions about benefits to be offered in the compensation package. It is evident that the success of a health-care organization is dependent on having a nurturing and supportive staff attitude toward patients; quality of staff interaction with patients is key to successful marketing efforts. A recent study of patient satisfaction indicated that the three top success indicators all related to the patients’ perception of how they were treated by the nurse (Finkler & Kovner, 1993).
Government-Funded Programs All levels of government are providers of health-care services, e.g.,military and veterans’ hospitals, and payers for
Salaries. Salaries and benefits represent the single largest cost in the operational budget; this item should not exceed 60% of gross revenue (Finkler & Kovner, 1993). Wages and benefits should be competitive with other employers in the area. This information can be obtained by a market survey. Fringe benefits are costs of em-
668 J 0 G
Volume 23. Number 8
:V N
Home Care
ployees in addition to their salary and typically include Social Security taxes, health and life insurance, and other employee taxes and benefits. Each organization will calculate a benefit rate, but these rates commonly range from 22% to 23% of gross salary. Hiring. Staff turnover is expensive; one study estimated the mean turnover cost per registered nurse at $10,198 (Finkler 8r Kovner, 1993). Managers of perinatal homecare programs are wise to seek and retain personnel who offer a balance of perinatal knowledge, skill, and sensitivity to client needs. Taking time to d o careful interviewing and reference checks is essential to the creation of a successful team. Information available through reference checks with previous employers can be limited because of current human resources policy. Often the only information released is dates of employment and eligibility for rehire. Offering applicants an opportunity to observe or accompany a current employee doing the actual job may provide additional information about the individual’s potential for success in the new role. Involving staff in the interview process also can be effective in screening for individuals who will be successful in perinatal home care. In any situation in which staff members express reluctance to support hiring of an applicant, the responsible manager is well advised to take additional time to interview and evaluate the individual. Home care is unique; not all nurses will make a successful transition from other areas of health care. Patients referred for perinatal home-care services usually will have significant risks and complications. In the home, the nurse will not have the access to consultation and collaboration with peers and other care providers that is available in the acute care setting. Independence in clinical assessment and judgment are required. Hospital acute care experience usually provides the best background for this added responsibility. Scheduling. Home-care nurses generally can be expected to spend one-third of their working hours in travel, one-third in providing care, and one-third in documentation. Because the patient visit is the only reimbursable portion of this time, scheduling and organization of patient-care activities is essential for financial success of the program. Nurses will need to consider planning the most efficient routes for travel to avoid heavy traffic times and locations; planning visits by geographic proximity; organizing supplies, chart forms, and other required paperwork, such as billing forms and expense reports; ensuring that patients will be at home and prepared for the visit; and setting realistic expectations by patients for the length and purpose of each visit. As in the acute care obstetric setting, the home-care census will fluctuate unpredictably. New referrals usually need to be seen within 24 hours and often sooner. This presents a challenge for scheduling of staff and visits. The home-care supervisor must demonstrate the creativity and flexibility to accommodate all of these demands. For example, nurses can be offered an incentive, such as a
Ocloher 1994
bonus or paid time off, if they meet or exceed a daily or weeklyvisit expectation and provide timely, complete records for billing. Home-care services require around-the-clock availability of nursing staff. At least 1.4 full-time employee equivalents must be hired to provide 7-day per week coverage, with additional employees needed to cover nonproductive time (sick, vacation, holiday, and other paid nonworked hours, such as orientation and in-service time). Nonproductive time can be expected to equal approximately 15% of worked hours; this percentage will vary with tenure and benefits, and can be calculated for a specific staff based o n historical data and known benefits. Unless these nonproductive hours are budgeted and coverage is planned, undesirable and costly overtime salary expense will be incurred. In addition, staff likely will begin to feel overworked and frustrated; poor performance and errors in care or documentation will follow, and resultant staff turnover will be excessive and costly. Orientation and training. A comprehensive, organized orientation and training program will prepare nurses to practice effectively and safely in the home. In addition to adapting perinatal clinical knowledge and skills to this new practice environment, the nurse will need time to master the unique skills for providing care in the home. Documentation of this training, including skill checklists and outlines of class content, will be reviewed in some detail during licensure o r certification visits. Annual recertification and documentation of competency for all staff will be expected. In addition to the benefits of compliance with regulatory requirements, a good orientation and training program promotes job satisfaction. Nurses’ ability to know and perform their responsibilities is promoted by a program in which required knowledge and skills are reviewed and validated during orientation and at least annually thereafter. An example of a content outline for orientation to perinatal home care is shown in Table 1. Equipment Perinatal home care goes beyond the range of usual home-care services provided; the diagnoses are more acute and require greater nursing clinical judgment and technical skill. The equipment requirements for this high level of care represent a significant financial commitment. Several models of equipment may be required for one type of service. For example, monitoring of preterm uterine activity may be done best by a monitor with guard-ring technology, whereas maternal-fetal surveillance requires a state of-the-art electronic fetal monitor; intravenous hydration for hyperemesis gravidarum requires different pump capabilities than does the subcutaneous infusion of tocolytic medication for preterm labor. It is important to determine whether equipment will be needed daily, weekly, or only occasionally and compare costs of purchase, lease, and rental of such equipment. When evaluating the cost of purchasing or leasing compared with renting, hidden costs such as storage,
J 0 CN N
669
C L I N I C A L
I S S L ’ E S
Table 1 . Content Outlinefor Orientation to Home Care
agencies, sharing or contracting for clerical services and equipment maintenance may be the best option.
I . Assessment
A. Physical
B. Psychosocial C . Home environment D. Risk identification 111.
Documentation A. Clinical
B. Reimbursement/billing/expenses IV. Equipment and supplies A. Use and safety
B. Maintenance V. Standards A. OSHA, JCAHO B. Professional/licensure
C. Organizational VI. Operations A. Organizational structure
B. Scheduling C. Human resource policy and
procedure 1. Performance management program 2 . Job responsibilities/expectations D. Payroll VII. Home care as a business A. Marketing and sales B. Budget/revenue/expense VIII. Quality improvement A. Internal and external customers B. Customer service C. CQI program
transport, supplies and disposables, repair, maintenance, cleaning, and updating should be considered. Backup equipment is necessary any time a patient service or therapy is dependent on properly functioning equipment. Regular equipment maintenance must be documented; certification for accuracy and safety before each patient’s use is required for some types of equipment, such as infusion pumps. These records usually are reviewed in some detail during any site visit for licensure or certification. If the personnel in the agencydo not have the skills or capability to perform this ongoing maintenance and testing, it may b e prudent to contract with a clinical engineer from a hospital or other agency for these services. The home-care agency will need computer equipment to process documentation, insurance claims, and financial data and a variety of additional office equipment. Maintenance agreements must be considered for support of most leased or purchased equipment. For smaller
670 J O G N N
Supplies
Supply sources and delivery schedules must be established so that items needed for patient care and other essential clerical and maintenance functions will be readily available. Most vendors are eager to assist with selection of items, establishing par levels, and arranging for delivery on an on-call-as-neededor regular basis. I t is wise to explore all alternatives and negotiate for the best deal among the vendors for similar products; prices are rarely fixed. In addition, expect excellent service and d o not hesitate to change vendors if service or price is not satisfactory. There are economies of scale in participating in larger volume purchasing contracts if these can be negotiated in cooperation with other programs or agencies. If a purchasing contract is considered, ensure that terms and conditions will make the contract void should service or product quality become unsatisfactory. Realistic par levels should be established and adjusted as indicated by experience and volume. Keeping stock at the minimum levels for efficiency and safety will help to control cost; patient charge items on the shelf in the office are “riding” on the program’s budget until those items are charged, billed, and reimbursed. It is more prudent to have those items on the vendor’s shelf and delivered to the agency as needed. An indjvidual in a support role should be responsible for regular ordering, stocking, and monitoring of supplies so that the persons providing direct care can depend on having the items they need. Give this individual responsibility and authority to manage this supply function; set high expectations for job performance and reward good results. Unnecessary time spent by nurses attempting to find, borrow, or substitute for a necessary item or rearranging visits because an item is unavailable is frustrating for the nursing staff and wasteful of the program’s most valuable resource. Remember: time is money. Billing and Reimbursement
The reimbursement function is specialized and requires a person who is knowledgeable about the business of perinatal home care and the payers. Each payer will have rules, exceptions, exclusions, and qualifiers for reimbursement. The reimbursement person has to know the rules, recognize that they may vary significantly among payers, and may change without advance notice. Before a patient is admitted for services, it is essential to ascertain the potential for reimbursement for the specific services by the specific payer based on the patient’s specific diagnosis and risk factors. Initiating services before insurance authorization (termed “clearing the patient”) may place the provider at risk for nonpayment, even if the services are subsequently authorized. Even an expert in reimbursement may spend several hours on the telephone attempting to clear one patient for services. It is wise to
Volume 23: Number 8
Home Care
hire the most qualified individual(s) for this responsibility, provide the necessary tools to do the job, and expect excellent results. Reimbursement for supplies and services is dependent on the billing process. If a supply item or visit is not charged, it cannot be billed; if it is not billed, it will never be reimbursed, and the agency will have to cover the cost out of its margin. This is not a complex concept; however, staff members who provide care and use supplies often are reluctant to accept this reality. The manager will be challenged to hold staff members accountable for completion of paperwork in a timely manner. It will be helpful to set firm expectations during staff orientation and to provide consequences for noncompliance with paperwork. The manager can assist by making certain the paperwork system is functional and efficient. Use of laptop computers for documentation in the field can be effective for clinical and reimbursement purposes. Billing and reimbursement efforts must be successful, or the business will not prosper, and all the employees will experience the negative results. Liability Insurance Liability insurance is not optional; a policy must be in place. If a program is associated with a hospital or agency, the existing coverage usually is sufficient. A nurse-owned small business will need to seek the appropriate coverage and ensure the adequacy of coverage from the professional and the business perspective. If an agency or program wishes to contract or associate with a hospital or other agency, proof of liability coverage usually is required. Nurses who work in home health-care programs may wish to examine the details of the agency’s liability insurance policy to ensure the adequacy of coverage for themselves as employees. Because home health care is more diverse than acute inpatient care, nurses may be performing broader functions with less supervision, and the language of the policy must address those issues. In addition, job descriptions for the nurses must clearly delineate responsibilities so that “scope of practice” is agreed upon by employee, supervisor, and patient. In the home, nurses will find themselves in many situations in which the patient or family may request assistance or services not included in the physician prescription and beyond defined nursing responsibility. The nurse must recognize these limits and be familiar with other resources to which she can refer clients.
Standards, Licensure, and Regulatory Issues Standards Standards are models and guidelines for practice established by agencies or organizations at local, state, or federal levels. Regardless of local practices, nurses are held to established national standards. Agency standards. Each agency will be required to have policies, procedures, and protocols to define and guide all elements of care the agency states that it offers. These
October 1994
standards must comply with established national standards; when policies necessarily deviate from standards because of the uniqueness of home care o r a particular population, a statement such as the following is suggested for the policy and procedure manual: We recognize the established standards of care for (condition or situation) call for (prevailing standard). We also recognize that there are inherent differences in providing this service in the home (or for this population). Under these circumstances, and for the specific reasons stated herein, we have adopted the following policy (or procedure). . . Manuals containing the agency’s statements of standards must be kept current and accessible to staff. During orientation, all employees who will be held to these standards must be provided with the time and opportunity to become familiar with the content of these documents. Annual review and awareness of additions and revisions should be required and ensured by managers. Organizational standards. One of the primary responsibilities of professional organizations is to create and define standards of care. For perinatal services, the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) is recognized as the national professional organization. AWHONN publishes competency statements, position papers, and practice guidelines. The NAACOG Standardsfor the Nursing Care of Women and Newborns (1991) provides written statements regarding scope of services, and policies, procedures, and protocols for antepartum and intrapartum home-care nursing practice. Standards set by other professional organizations, such as the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, and the American Hospital Association may influence standards for perinatal nurses. Legal standards. Legislated standards in addition to those addressing licensure will affect the home-care agency’s practices and conduct of business. Occupational Safety and Health Administration (OSHA) regulations, employment standards such as wage/hour and equal opportunity laws, and taxation laws are examples of these additional standards. Payer standards. Insurance companies and other payers may establish standards for care required for reimbursement of authorized services. The home-care agency must be able to demonstrate through documentation that the standards are met, or payment of claims may be denied. Licensure Licensure is a mandate by a regulating body. Professionals are required to be licensed to practice within their specialty (i.e., registered nurse; home health-care agencies must be licensed to provide care in most states; businesses are licensed to operate within a municipality). Licensing requirements vary from state to state and within
J O C N N
671
C L I .b I C A L
I S S I‘ E S
local jurisdictions. State licensure regulations can be determined by contacting the state’s Departments of Health or Licensing. Unique programs such as perinatal services may find that it is difficult and confusing to adapt existing regulations to the specialty services of perinatal h o m e care. Extensive dialogue between the home-care providers and the regulatory agency may b e needed to complete the licensure process. Certijcation Certification usually is a voluntary process. For example, perinatal nurses may choose to be certified in their specialty by an organization such as the National Certification Corporation. Provider organizations may elect to b e certified by the Joint Commission for Accreditation of Healthcare Organizations (JCAHO). Although JCAHO certification is considered voluntary, there are implications for reimbursement and contracting with third-party payers when the agency is not certified. O n J u n e 1, 1988, JCAHO added standards for durable medical equipment, infusion therapy, pharmacy, and coordination of care among providers. Only hospitals are held to these standards at this time; however, third-party payers are identifying a need for national standards for all services and may adopt those set by JCAHO (WillHome Care Re Round bji.JCAHOStavzdards?, 1988).
Continuous Quality Improvement Programs addressing quality issues have been evident in health care for some time. The earlier focus o n retrospective review and identification of problems has given way to concurrent review and programs for continuous quality improvement (CQI). All employees of a n organization are expected to participate actively in the CQI program. Clinical CQI The licensed or certified home-care agency will b e required to demonstrate an active C Q I program. All e m ployees are expected t o b e familiar with the program and able to articulate the process during scheduled and unannounced site visits f o r accreditation or licensure. The challenge for facilitators of the CQI program is to make it a useful tool for demonstrating success and determining the focus for changes and adjustments in current practice. Outcome information from CQI monitors should b e the basis for changes in policies and procedures and for e d u cational and in-service efforts. O n c e an employee has experienced a positive, useful outcome from the CQI process, h e or she will b e much more likely to b e an active, compliant participant in the program.
hospitals, clinics, and other referral sources. Internal customers include colleagues and peers; other departments, such as billing and purchasing; support personnel, such as clerical and maintenance; and managers. Successful organizations strive for continued excellence in internal a n d external customer service. The organization’s image is created from within and begins with the attitude and actions of each individual. When respect and courtesy are extended to every internal customer with the same e n thusiasm and commitment often reserved for external customers, results are overwhelmingly positive. External customers are the source of the business. Agencies that have not offered perinatal services in the past are creating n e w divisions and services to market, and this area of h o m e health care has become extremely competitive. If a n agency does not take good care of its customers, someone else will. Service excellence in this business means “doing it right” every time. This attitude is epitomized in a comment from a n astute home-care nurse. She stated, “The patient is always right; even when patient is not right, my agency and I will make it right for the patient.” CQI monitors of internal a n d external customer service are revealing and rewarding. When the organization and individuals are providing good service, CQI outcomes are visible acknowledgment. When CQI monitors demonstrate problems in performance or customer service, the data that have been obtained clearly define the focus for training a n d counseling that can correct t h e deficiencies.
Marketing Perinatal Home Care m a t Is the Product? The product provided by perinatal home-care services is nursing care. Equipment, supplies, and drugs are billable components of the h o m e care, but the unique and valuable commodity being marketed by the agency is the knowledge, skill, sensitivity, support, and hands-on care delivered by the nurse in the home.
Custpmer Service and CQI For any organization, the customer is defined as any individual or group receiving the services of another individual or group. Customers may b e “external” or “internal.” Examples of a home-care agency’s external customers are patients, families, physicians, insurance case managers,
Home Care:A Relationship Business Home care is a relationship business; referrals and business growth are achieved as a result of establishing positive relationships with internal and external customers. The prudent manager recruits individuals with exceptional “people skills” and existing networks with perinatal health-care providers and payers. Marketing a service is different from marketing equipment or pharmaceuticals; techniques that bring positive results in selling birth control pills or birthing beds may not b e effective for marketing services. It is not possible to provide free samples or bring in a model for trial. Without input and training from the agency’s nursing staff, it will be‘difficult for the sales and marketing staff to gain the full understanding of the product and the customers that will lead to successful sales and marketing efforts. The people component is the key to presenting this
672 / O G A ’ h ’
Volume 23. Number 8
Home Care
product. Establishing the relationship takes time; the approach must be tailored to the individual or group; trust must be established; consistency, reliability, and dependability are building blocks for this relationship. Once the relationship is established, it must be nurtured and maintained for continued success. The competition will be at the door; a large customer referral source will be the prime target for every other agency seeking to provide the same product.
Marketing in the Managed Care Environment Managed care is a system in which an individual, such as a nurse case manager, determines what is necessary for the patient and authorizes the care and services (Finkler Lk Kovner, 1993). The case manager is an intermediary between the provider of services and the patient. The goal of managed care is to decrease the costs of health care by identifying and authorizing only those services deemed to be “necessary.” Case management may eliminate some services but also can ensure that patients receive appropriate and timely care. Case managers are significant external customers; marketing the perinatal home-care services to these individuals will become increasingly important as their role expands throughout the industry. Case managers will drive and direct care for most, if not all, potential perinatal and neonatal patients. These individuals should be at the top of the priority list for relationship development if the perinatal home-care service is to survive and thrive in this tapidly changing health-care environment.
zons by bringing their expertise and skills to home care. The experience will challenge the nurse by tapping areas of nursing assessment and intervention that extend beyond the scope encountered in the hospital or clinic. Home care has multiple models for care. Operational issues, standards, and assessments of quality have some common ground in all health-care environments; however, the arena of home care has unique attributes that must be understood and appreciated for successful development, marketing, and delivery of services.
References DeVore, N. (1990). Maternal psycho social adaptations to high risk pregnancy. In K. A. Buckley & N. A. Kulb (Eds.), High risk maternity nursing (pp. 15-19). Baltimore: Williams & Wilkins. Evans, C. (1991). Description of a home follow-upprogram for childbearingfamilies.JOGNN, 20, 113-118. Finkler, S., & Kovner, C. (1993). Financial management for nurse managers a n d executives. Philadelphia: WB Saunders. Humphrey,C. J. (1988).The home as a setting for care. Nursing Clinics ofNorth America, 23,305-314. NAACOG. (1991). NAACOG standards for the nursing care of women a n d newborns (4th ed.).Washington, DC: Author. Rogatz, P. (1987). Perspective on home care. Public Health Nursing, 4, 7-8. Will home care be bound by JCAHO standards? (1988). Hospitals, G2,57.
Conclusion
Address for correspondence: Linda Goodwin, RNC, MEd, Labor and Delivery, Sentara Norfolk General Hospital, 600 Gresham Drive, Norfolk, VA 23507.
Home care will continue to expand in the specialty of women’s and children’s services. This offers an excellent opportunity for experienced nurses to expand their hori-
Linda Goodwtn is the nurse manager tn the Labor and Delivery Department of the WomenS Health Pavilton, Sentara Norfolk General Hospttal, Norfolk, VA.
October 1994
J O G N N 673