- Email: [email protected]
Partnering for success
Minding Our Business
Partnering for Success BY LINDA BURMAN GOOKIN, MPA, BSN, RN
Partnering has not been the philosophy of most providers and educators, Rather, providers filled a need requested by educational institutions. Visiting Nurse Associations (VNAs) along with other agencies who had nursing education as part of their mission, have had a long tradition of providing preceptorships for generic baccalaureate nursing students. Usually the precepted students were in their senior year of nursing school and had completed their medical-surgical experience. Before the community health program began, most of their clinical education occurred in the acute hospital setting. As part of their community health experience, some schools of nursing placed one clinical group in one agency (public health or home care) with one instructor who worked with the agency staff in guiding the clinical experience. In other schools, students were divided between the public health department, other community agencies, and VNAs. With this model, the faculty member coordinated the experience and the students worked with an agency preceptor (staff nurse) selected by
BUSINESS
102
HOME
CARE PROVIDER
the agency administration in collaboration with the instructor. Generally this experience was limited to four to six students in one setting. Because not all students shared a common setting, instructors had to divide their time among a number of facilities. As a result, the major burden of precepting fell on the staff nurses and then- managers. For many years these models were generally followed. They seemed to work, though there never seemed to be enough placements in community settings for students. Over the past 5 years, increased costs, shrinking reimbursement, increased productivity standards, and shrinking health departments, have made student placement more difficult. In home health care, with the advent of paying nurses by the visit, precepting a student lost its appeal because it slowed the nurse down and had a negative economic impact. Many agencies who wanted to retain students became creative and found ways to offset this impact, For example, some agencies allowed students to make independent visits toward the end of their rotation and the visits were charged to the payor so there was not a major negative financial impact on the agency. MARCH/APRIL
1996, VOL. 1 NO. 2
MINDING
OUR BUSINESS
GOOKIN
Although I wouldn’t classify this arrangement as a partnership between the school and agency, it fulfilled their mutual needs. Nevertheless, it became increasingly difficult to afford students. During the last 5 years, three other major events occurred in the educational arena. First, nursing programs were developed for working RNs to earn BSN degrees. Although these programs were needed, they were less structured than generic BSN programs. In many cases, the students had to find their own community health placements. This placed additional responsibility on the students and agency. Many times the faculty and the agency did little pre-planning for these placements, and the students seemed to call the agency at the last minute desperately seeking a preceptorship. Secondly, because of the difficulty obtaining community health placements for students, agencies were frequently requested to arrange for students to make a 1 -day observation in the field as an alternative to the usual multi-week clinical experience. Instructors believed that an observation visit was better than nothing. In my opinion, this arrangement did not allow a student true insights into home care and placed an undue burden on the agency. Field observation visits have a negative impact on productivity. Unlike preceptorships, the agency gains nothing in return for the investment of time. The third event was that Associate Degree in Nursing (ADN) programs began requesting field placements for their students. The nursing shortage, the increased acuity of patients, and the fact that there was no differentiated practice in home care in many agencies helped to change the notion that only BSNs with their community health theory base can function in home care. Nevertheless, it was difficult for agencies to stretch limited resources to include ADN preceptorships in home health care. Given recent changes in home care, with the increase of managed care and the prospect of some form of prospective pay on the horizon, it is clear that we have a nursing work force that is not prepared for these changes. Just as the skills of currently employed nurses must change, so must the skills of students entering the nursing profession. To cite just one example of a critical change, let us look at case management. Most traditional home care agencies had an institutional model of case management in place. The case manager coordinated the care provided by specialists in various disciplines within the agency as well as with external community resources specific to a patient or group of patients. The case manager was responsible for determining a patient’s care needs, but had little responsibility for weighing those needs against financial limitations. The case manager’s financial responsibility was limited to documenting skilled care accurately so that care would be reimbursed. Communication was relatively simple, and occurred between the case manager and the physician. In a managed care environment, this is changing. The agency case manager must now communicate with an external MARCH/APRIL
1996,
VOL.
1 NO.
2
case manager. Moreover, the case manager must justify the reasons the care is being delivered in terms of expected outcomes. Furthermore, because of the acuity of patients and because physicians have more patients being managed at home, it is imperative that the nurse have the skills to determine when to call the physician and work collaboratively so unnecessary calls are not made. In other words, the skills of the case manager are rapidly changing. As a result, there are implications both for currently employed nurses whose skills need to be upgraded as well as for students being prepared for the future. To compound these changes, the case manager’s role in health care today is continually evolving. Nurses at various educational levels are expected to function as case managers in the home health care setting and in other settings, although nurses with higher skill levels or advanced degrees may case manage patients with more complex needs. In addition to excellent clinical skills, the case manager of the future will need excellent communication skills, negotiating and conflict resolution skills, critical thinking skills, financial management skills, and the ability to work in a continuously changing environment. Those of us in home care today must expect to educate our work force so that the skills of the current case managers are enhanced. If we re-tool some of our current staff, this means that case managers may continue to have varied educational backgrounds. As the role of the case manager in home health care evolves and shifts to require a more highly skilled nurse, there remains a role for staff nurses who partner with case managers. Potentially this staff nurse role could be filled by a nurse with an ADN. The clarification of roles is evolving daily as we learn to manage our business in this new environment. Are educators aware of the specific changes occurring in home health care? If they are not, I suggest as a first step that they take the initiative to meet with the providers in their area to become more knowledgeable and to begin to explore the possibility of partnering. Several years ago, I sent a letter to the five BSN schools in our geographic area suggesting that if they were interested in looking at student experiences in new ways, our organization would explore opportunities with them. We received only one response. Although we were initially disappointed at the lack of response, taking this step enabled us to forge a partnership that more than a year later is working well and benefiting all. In exchange for having an instructor on site during the time the students were present, we allowed 10 or 11 students to be precepted at our agency. In return, the instructor agreed to be fully oriented to the role of a visiting nurse and learn our policies and procedures. The instructor was able to have her students in one location, and the responsibility for precepting them became shared by the staff nurse and the instructor. This model requires the educator to accept change and have the courage to learn new skills. As mentioned previously, health care is moving into HOME
CARE PROVIDER
103
MINDING
GERIATRIC
[email protected]
nurses
and nurse
managers who care for older adults in hospitals, nursing homes, senior centers, or private homes.
HEART & LUNG@: THE JOURNAL OF ACUTE AND CRITICAL Cm...presenting original, peer-reviewed articles on techniques, advances, investigations, and observations relating to critical care.
A?&w!HoME CARE PROVIDER...a unique multidisciplinary journal meeting the needs of the entire home care team, with articles that emphasize results and practical information. A&W/ INSIGHT-THE THExkMERICANSOCIE'I-YOF
OF
JOURNAL
OPHTHALMIC REGISTERED NURSES ..providing coverage of clinical and scientific advances, professional nursing issues, and legislative concerns for the ophthalmic nurse.
INTERNATIONALJOURNAL N~~~~~~...covering
all facets
OF TRAUMA
of trauma
care,
including flight, emergency, perioperative, medical/surgical, anesthesia, critical care, and rehabilitation nursing.
JOURNAL OFTHEAMERKANPSYCHIATRIC NURSES
&5SOCIATION...covering
psychiatric/mental
health issues relevant to nurses working in hospitals, residential treatment programs, nursing homes, home care, and independent practice.
JOURNAL OF
EMERGENCYN~~~~~...covering
professional, political, aspects of emergency
administrative, nursing.
and educational
JOURNAL OF PEDMTRIC HEAKI-H CARE ...featuring articles on a broad range of issuesand clinical problems facing newborn, pediatric, and adolescent patients. JOURNAL OF VASCULAR NUR.SING...providing the latest information relating to the education, diagnosis, treatment of patients with vascular disease.
and
OUR BUSINESS
the community. Nurses entering the field of home care are required to have at least some acute care experience. Where will they get this experience? New graduates are unable to find positions in acute care. Home health care agencies do not have the resources to provide transitional training or preceptoring for graduate nurses. Curriculum changes could provide students with more than one semester in home health care, or perhaps the time has come to seriously explore internships for nurses. Partnering is a way to share or exchange resources. The possibilities are limitless. Preceptors with a responsibility to nurture new members of their profession need support and can enhance their teaching skills by working with an educator. In exchange for agency staff participating in student education or speaking to groups of students, educators could provide courses or training for agency staff in areas such as finance or development of critical thinking skills. Joint appointments of clinical faculty to an agency or agency staff to the educational institution are possibilities. Partnering students with staff during the summer could be a way for students to gain additional experience and potentially earn some money. Educators and agency administrators serving on each others’ advisory boards is a way to keep abreast of the changes and challenges in both environments. It is a way for educators to stay abreast of the skills needed in the future workforce. I think we can all agree that agencies need competent nurses and educational institutions want to graduate competent nurses. Forging partnerships and pooling our limited resources is the only way to assure the development of a skilled nursing workforce for the future. But we must act quickly. Just as agency administrators and their staff must respond rapidly to our dynamic environment, so too must educators. n Reprint no. 69/l/12703
JOURNALOF WOCN (WOUND,~STOMY AND CONTINENCE NURSING) . ..forET nurses and other specialty nurses caring for patients with stomas, wounds, fistulas, pressure ulcers, and incontinence.
NURSING educators, insightful nursing.
[email protected]
nurse
administrators, policy makers, and practitioners articles examining current issues and trends
UROLOGIC educational,
[email protected] and research problems facing
with in
clinical, urologic nurses,
physician assistants, and technicians.
Sharing in All Dimensions--continued
from page 101
REFERENCES I. Goldberg Al. Home healthcare: The role of the primary care physician. Comprphensive
rd Mosby To subscribe or obtain moreinformation,contact: Mosby-Year
Book, Inc., Journal Subscription Services 11830 Westline Industrial Drive, St. Louis, MO 63146 U.S.A. Call toll-free: l-800-453-4351. Outside the U.S., call: 314-453-4351. Fax: 314-432-1158 See OUT catalog on the World Wide Web at www. mosby. corn
104
HOME
CARE
PROVIDER
Therapy 1995;21:633-8. 2. KeenanJM, Boling PA, Schwartzberg JG, et al. A national survey of the home visiting practice and attitudes of family physicians and interns. Arch kern Ned 1992;152:2025-32. 3. Boling PA, Keenan JM, Schwartzberg JG, Retchin SM, Olson 1. Home health agency referrals by internists and family physicians. / Am Geriatr Soc 1992;40:1241-9. 4. Goldberg Al, Monahan CA. Home health care for children assisted by mechanical ventilation: The physicians’s perspective. J Pediatr 1989;114:378-83. 5. Brown JG. The Physicians’ Role in Home Health Care. Washington DC: Office of the Inspector General, U.S. Department of Health and Human Services, June 1995. Reprint no. 69/l/72704
MARCH/APRIL
1996,
VOL.
I NO.
2
Partnering for Success BY LINDA BURMAN GOOKIN, MPA, BSN, RN
Partnering has not been the philosophy of most providers and educators, Rather, providers filled a need requested by educational institutions. Visiting Nurse Associations (VNAs) along with other agencies who had nursing education as part of their mission, have had a long tradition of providing preceptorships for generic baccalaureate nursing students. Usually the precepted students were in their senior year of nursing school and had completed their medical-surgical experience. Before the community health program began, most of their clinical education occurred in the acute hospital setting. As part of their community health experience, some schools of nursing placed one clinical group in one agency (public health or home care) with one instructor who worked with the agency staff in guiding the clinical experience. In other schools, students were divided between the public health department, other community agencies, and VNAs. With this model, the faculty member coordinated the experience and the students worked with an agency preceptor (staff nurse) selected by
BUSINESS
102
HOME
CARE PROVIDER
the agency administration in collaboration with the instructor. Generally this experience was limited to four to six students in one setting. Because not all students shared a common setting, instructors had to divide their time among a number of facilities. As a result, the major burden of precepting fell on the staff nurses and then- managers. For many years these models were generally followed. They seemed to work, though there never seemed to be enough placements in community settings for students. Over the past 5 years, increased costs, shrinking reimbursement, increased productivity standards, and shrinking health departments, have made student placement more difficult. In home health care, with the advent of paying nurses by the visit, precepting a student lost its appeal because it slowed the nurse down and had a negative economic impact. Many agencies who wanted to retain students became creative and found ways to offset this impact, For example, some agencies allowed students to make independent visits toward the end of their rotation and the visits were charged to the payor so there was not a major negative financial impact on the agency. MARCH/APRIL
1996, VOL. 1 NO. 2
MINDING
OUR BUSINESS
GOOKIN
Although I wouldn’t classify this arrangement as a partnership between the school and agency, it fulfilled their mutual needs. Nevertheless, it became increasingly difficult to afford students. During the last 5 years, three other major events occurred in the educational arena. First, nursing programs were developed for working RNs to earn BSN degrees. Although these programs were needed, they were less structured than generic BSN programs. In many cases, the students had to find their own community health placements. This placed additional responsibility on the students and agency. Many times the faculty and the agency did little pre-planning for these placements, and the students seemed to call the agency at the last minute desperately seeking a preceptorship. Secondly, because of the difficulty obtaining community health placements for students, agencies were frequently requested to arrange for students to make a 1 -day observation in the field as an alternative to the usual multi-week clinical experience. Instructors believed that an observation visit was better than nothing. In my opinion, this arrangement did not allow a student true insights into home care and placed an undue burden on the agency. Field observation visits have a negative impact on productivity. Unlike preceptorships, the agency gains nothing in return for the investment of time. The third event was that Associate Degree in Nursing (ADN) programs began requesting field placements for their students. The nursing shortage, the increased acuity of patients, and the fact that there was no differentiated practice in home care in many agencies helped to change the notion that only BSNs with their community health theory base can function in home care. Nevertheless, it was difficult for agencies to stretch limited resources to include ADN preceptorships in home health care. Given recent changes in home care, with the increase of managed care and the prospect of some form of prospective pay on the horizon, it is clear that we have a nursing work force that is not prepared for these changes. Just as the skills of currently employed nurses must change, so must the skills of students entering the nursing profession. To cite just one example of a critical change, let us look at case management. Most traditional home care agencies had an institutional model of case management in place. The case manager coordinated the care provided by specialists in various disciplines within the agency as well as with external community resources specific to a patient or group of patients. The case manager was responsible for determining a patient’s care needs, but had little responsibility for weighing those needs against financial limitations. The case manager’s financial responsibility was limited to documenting skilled care accurately so that care would be reimbursed. Communication was relatively simple, and occurred between the case manager and the physician. In a managed care environment, this is changing. The agency case manager must now communicate with an external MARCH/APRIL
1996,
VOL.
1 NO.
2
case manager. Moreover, the case manager must justify the reasons the care is being delivered in terms of expected outcomes. Furthermore, because of the acuity of patients and because physicians have more patients being managed at home, it is imperative that the nurse have the skills to determine when to call the physician and work collaboratively so unnecessary calls are not made. In other words, the skills of the case manager are rapidly changing. As a result, there are implications both for currently employed nurses whose skills need to be upgraded as well as for students being prepared for the future. To compound these changes, the case manager’s role in health care today is continually evolving. Nurses at various educational levels are expected to function as case managers in the home health care setting and in other settings, although nurses with higher skill levels or advanced degrees may case manage patients with more complex needs. In addition to excellent clinical skills, the case manager of the future will need excellent communication skills, negotiating and conflict resolution skills, critical thinking skills, financial management skills, and the ability to work in a continuously changing environment. Those of us in home care today must expect to educate our work force so that the skills of the current case managers are enhanced. If we re-tool some of our current staff, this means that case managers may continue to have varied educational backgrounds. As the role of the case manager in home health care evolves and shifts to require a more highly skilled nurse, there remains a role for staff nurses who partner with case managers. Potentially this staff nurse role could be filled by a nurse with an ADN. The clarification of roles is evolving daily as we learn to manage our business in this new environment. Are educators aware of the specific changes occurring in home health care? If they are not, I suggest as a first step that they take the initiative to meet with the providers in their area to become more knowledgeable and to begin to explore the possibility of partnering. Several years ago, I sent a letter to the five BSN schools in our geographic area suggesting that if they were interested in looking at student experiences in new ways, our organization would explore opportunities with them. We received only one response. Although we were initially disappointed at the lack of response, taking this step enabled us to forge a partnership that more than a year later is working well and benefiting all. In exchange for having an instructor on site during the time the students were present, we allowed 10 or 11 students to be precepted at our agency. In return, the instructor agreed to be fully oriented to the role of a visiting nurse and learn our policies and procedures. The instructor was able to have her students in one location, and the responsibility for precepting them became shared by the staff nurse and the instructor. This model requires the educator to accept change and have the courage to learn new skills. As mentioned previously, health care is moving into HOME
CARE PROVIDER
103
MINDING
GERIATRIC
[email protected]
nurses
and nurse
managers who care for older adults in hospitals, nursing homes, senior centers, or private homes.
HEART & LUNG@: THE JOURNAL OF ACUTE AND CRITICAL Cm...presenting original, peer-reviewed articles on techniques, advances, investigations, and observations relating to critical care.
A?&w!HoME CARE PROVIDER...a unique multidisciplinary journal meeting the needs of the entire home care team, with articles that emphasize results and practical information. A&W/ INSIGHT-THE THExkMERICANSOCIE'I-YOF
OF
JOURNAL
OPHTHALMIC REGISTERED NURSES ..providing coverage of clinical and scientific advances, professional nursing issues, and legislative concerns for the ophthalmic nurse.
INTERNATIONALJOURNAL N~~~~~~...covering
all facets
OF TRAUMA
of trauma
care,
including flight, emergency, perioperative, medical/surgical, anesthesia, critical care, and rehabilitation nursing.
JOURNAL OFTHEAMERKANPSYCHIATRIC NURSES
&5SOCIATION...covering
psychiatric/mental
health issues relevant to nurses working in hospitals, residential treatment programs, nursing homes, home care, and independent practice.
JOURNAL OF
EMERGENCYN~~~~~...covering
professional, political, aspects of emergency
administrative, nursing.
and educational
JOURNAL OF PEDMTRIC HEAKI-H CARE ...featuring articles on a broad range of issuesand clinical problems facing newborn, pediatric, and adolescent patients. JOURNAL OF VASCULAR NUR.SING...providing the latest information relating to the education, diagnosis, treatment of patients with vascular disease.
and
OUR BUSINESS
the community. Nurses entering the field of home care are required to have at least some acute care experience. Where will they get this experience? New graduates are unable to find positions in acute care. Home health care agencies do not have the resources to provide transitional training or preceptoring for graduate nurses. Curriculum changes could provide students with more than one semester in home health care, or perhaps the time has come to seriously explore internships for nurses. Partnering is a way to share or exchange resources. The possibilities are limitless. Preceptors with a responsibility to nurture new members of their profession need support and can enhance their teaching skills by working with an educator. In exchange for agency staff participating in student education or speaking to groups of students, educators could provide courses or training for agency staff in areas such as finance or development of critical thinking skills. Joint appointments of clinical faculty to an agency or agency staff to the educational institution are possibilities. Partnering students with staff during the summer could be a way for students to gain additional experience and potentially earn some money. Educators and agency administrators serving on each others’ advisory boards is a way to keep abreast of the changes and challenges in both environments. It is a way for educators to stay abreast of the skills needed in the future workforce. I think we can all agree that agencies need competent nurses and educational institutions want to graduate competent nurses. Forging partnerships and pooling our limited resources is the only way to assure the development of a skilled nursing workforce for the future. But we must act quickly. Just as agency administrators and their staff must respond rapidly to our dynamic environment, so too must educators. n Reprint no. 69/l/12703
JOURNALOF WOCN (WOUND,~STOMY AND CONTINENCE NURSING) . ..forET nurses and other specialty nurses caring for patients with stomas, wounds, fistulas, pressure ulcers, and incontinence.
NURSING educators, insightful nursing.
[email protected]
nurse
administrators, policy makers, and practitioners articles examining current issues and trends
UROLOGIC educational,
[email protected] and research problems facing
with in
clinical, urologic nurses,
physician assistants, and technicians.
Sharing in All Dimensions--continued
from page 101
REFERENCES I. Goldberg Al. Home healthcare: The role of the primary care physician. Comprphensive
rd Mosby To subscribe or obtain moreinformation,contact: Mosby-Year
Book, Inc., Journal Subscription Services 11830 Westline Industrial Drive, St. Louis, MO 63146 U.S.A. Call toll-free: l-800-453-4351. Outside the U.S., call: 314-453-4351. Fax: 314-432-1158 See OUT catalog on the World Wide Web at www. mosby. corn
104
HOME
CARE
PROVIDER
Therapy 1995;21:633-8. 2. KeenanJM, Boling PA, Schwartzberg JG, et al. A national survey of the home visiting practice and attitudes of family physicians and interns. Arch kern Ned 1992;152:2025-32. 3. Boling PA, Keenan JM, Schwartzberg JG, Retchin SM, Olson 1. Home health agency referrals by internists and family physicians. / Am Geriatr Soc 1992;40:1241-9. 4. Goldberg Al, Monahan CA. Home health care for children assisted by mechanical ventilation: The physicians’s perspective. J Pediatr 1989;114:378-83. 5. Brown JG. The Physicians’ Role in Home Health Care. Washington DC: Office of the Inspector General, U.S. Department of Health and Human Services, June 1995. Reprint no. 69/l/72704
MARCH/APRIL
1996,
VOL.
I NO.
2