AHCA Panel - Do you have the right Clinical Staff

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					61st Annual AHCA/NCAL Annual Convention

W-5 – Panel Discussion:
Do you have the right Clinical Staff?

 Identify the clinical skills required to meet acuity levels
 Learn what constitutes effective physician coverage and skill set
 Understand the advantages of using NPs and RNs
 Learn how to implement appropriate staffing within current budgets

Tale of Two Nursing Centers

Nursing # of     DC      DC      DC Total Nursing & Last three
Center Beds     Expire Hospital Home Therapy PPD Annual Surveys

  A      126 64%        8%     13%        3.72       Def FREE

  B      120    9%      20% 67%           4.97       State Avg

      Two Nursing Centers of similar size, with very different
       populations requiring different staffing considerations
   A Tale of Two Nursing Centers
   The Rest of the Story

 Center       DC         DC      DC     DC                DC          DC       Nrsg &
 Name        Home      Hospital Other Nur Cen            Expire      Total    Ther PPD

   A          16          10         18          1        80         126       3.72
             13%          8%                             64%
   B        1222         363         32         43        159       1819       4.97
            67%          20%                              9%
Center A – Boston suburb: Alzheimer’s Care Center caring for Long Stay Residents;
Consumer Reports Recommend List; Last three annual surveys were Deficiency Free.
AHCA Bronze and Silver Quality Award recipient. Small therapy staff but robust
restorative nursing program, no RT. Strong Social Services and nutrition services.

Center B – Greater Los Angeles area, located on hospital campus: Heavy Managed
Care volume of higher acuity short stay patients; Doctors & NPs round in Center
daily; robust therapy services including respiratory; Center discharges about 100
patients to HOME per month. Good care, but struggles with survey compliance.
Identify the clinical skills required to meet
acuity levels

               Irene Fleshner

Clinical Staffing Considerations

• Who do we care for ?
  – scope of services, IVs, acuity level, behavioral issues
• Numbers ?
  – census, admissions
• Model of care delivery ?
  – who does what
• Needs per shift ?
  – admissions, outside appointments
• Skill mix ?
  – role of licensed nurses - RNs vs. LPNs
• Staff competencies
What is Sufficient Clinical Staffing?

•   Federal & State requirements
•   CMS – Five Star
•   Budget
•   Resident/Patient needs
•   Staff preferences
•   Family preferences
•   Reimbursement

Clinical Support for Rising Acuity

• Clinical Professionals
  –   Nurses - RN and APRN
  –   MD, Podiatry, Optometry
  –   Psychology
  –   Social Work
• Therapy Professionals
  – PT, OT, Speech, Respiratory
• Case Management

Nursing Practice in SNFs Today

• Only 6% of RNs work in SNFs
• Majority licensed care provided by LPNs
• RNs typically do not deliver direct care to
  nursing home patients/residents
• Little differentiation in the licensed nurse
  roles and responsibilities

RN Competencies for Rising Acuity

• Clinical Skills
   – Geriatric Nursing
   – Post Acute Care
   – Rehab, Cardiopulmonary, Ortho
• Leadership
• Quality Improvement

  Evidence supporting the need to Focus on Professional

       • When RNs care for people living in SNFs fewer
         restraints are used, residents develop few infections,
         and are admitted to hospitals less often.
       • Nursing facilities that employ larger number of RNs
         receive fewer deficiencies on annual surveys.
       • Without the leadership of professional nurses, people
         living in nursing facilities experience many negative
         consequences – pressure ulcers, unexpected weight
         loss, increased urinary catheterization and decline in
Research in Gerontological Nursing, Vol.1, No.3, 2008

Learn what constitutes effective physician
coverage and skill set


Physician Characteristics

           What works                                What doesn’t
•   Medical Director involved,             •   Medical Director with the largest
    supportive, routinely in Center            private, ambulatory care practice
•   Interest in elderly and LTC            •   Indifferent, Ageist, too busy
•   Appreciates the needs of dementia      •   Fearful of psychiatric or behavior
    and behavior patients                      patients
•   Team player, appreciates               •   Rugged individualist; autonomous,
    contributions of IDT and Midlevel          anti-authoritarian to facility
    practitioners                              leadership
•   Is somewhat of a social scientist      •   Strictly medicine and high tech
•   Sees family as opportunity to          •   Views family members as difficult
    enhance understanding of patient           and interfering
•   Incorporates staff interventions and   •   Believes the prescription pad is the
    behavior modifications in Tx               holy grail
•   Understands Advance Directives         •   Thinks DNR means “do nothing”
•   Sees value in educating nursing        •   Critical of staff; “teaching is not my
    staff formally and informally              job”

Staff View of Medical Community

           What Works                                  What Doesn’t
•   Communication and outreach             •   Pretending they don’t exist
•   Telling your story by providing        •   Offering pens, penlights and
    patient outcomes data                      trinkets
•   Offering nursing assistance with       •   They are lucky we let them practice
    rounds, locating charts, exams, etc.       here
•   Teaching nursing staff how to be       •   Nursing staff is unprepared and/or
    prepared to communicate with docs;         disorganized during phone calls
    batching phone calls                       (does not have V/S or chart)
•   Find resources (AMDA) to educate       •   We barely have time to educate
    docs about regulations and policy          nurses, much less the docs
•   Remember, docs are trained in the      •   Docs should do what we tell them
    scientific method and respond              just because it is our facility policy
    accordingly                                or because “we said so”
•   Medical Advisory Boards with a         •   It is too difficult and time
    variety of members – case studies to       consuming to deal with the medical
    stimulate dialogue                         community
•   If you advocate for the docs, they     •   If we do anything for the docs, they
    will advocate for you                      will just want more
SNF Vs Hospital E/M Code Payments

 SNF CPT                 Payment              Hospital CPT          Payment
99304 Initial               $80.00                  99221 Initial    $90.00
99305 Initial              $112.00                  99222 Initial   $122.00
99306 Initial              $144.00                  99223 Initial   $180.00
99307 Subseq                $40.00             99231 Subseq          $37.00
99308 Subseq                $61.00             99232 Subseq          $67.00
99309 Subseq                $80.00             99233 Subseq          $96.00
99310 Subseq               $119.00                      N/A           N/A
99315 Disch                 $58.00              99238 Disch          $67.00
99316 Disch                 $76.00              99239 Disch          $96.00
Rounded to nearest dollar
Does not account for geographic adjustment factor

Understand the advantages of using NPs
and RNs

             Barbara Resnick

Advantages of using NPs and RNs
Registered nurses (RNs):                         Nurse Practitioners (NPs):
*have a 2-3 year associated degree or a 4
    year baccalaureate degree;                    are RNs who have completed a master’s degree
*treat patients;                                 and training in the diagnosis and management of
                                                 common and more complex medical conditions.
*educate patients and the public about
                                                  are generally licensed through BON.
    various medical conditions;
                                                  are considered "mid-level" providers similar to
*provide advice and emotional support to         physician assistants (PAs).
    patients' family members;                     treat both physical and mental conditions
*record patients' medical histories and          through comprehensive history taking, physical
    symptoms;                                    exams, ordering tests.
*help perform diagnostic tests and analyze        can serve as a patient's primary health care
    results;                                     provider.
*operate medical machinery, administer            can order tests, procedures, and make
    treatment and medications;                   referrals.
                                                  can bill for their services through Medicare
*help with patient follow-up and
*care services are bundled into daily rates of
*Licensure is with the BON.                                                                          16
Nurse Outcomes

• Decreased medication errors
• Improved assessment and early recognition
  of disease
• Improved fall prevention
• Improved MDS assessment and care
• Improved oversight of care and patient/family

Outcomes of NP Services
• Improvements in medication use- a 17 per cent reduction in
  overall drug costs, a 55 per cent decrease in polypharmacy
  rates and a 63 per cent reduction in antipsychotic drug use.
• Decreased transfer to the emergency room -decreased by 20
  per cent.
• Improved family satisfaction with the quality of health care
  provided to residents- increased by 24 per cent.
• Decreased hospital admissions from the nursing home – a 39-
  43% decrease of cases has been reported.
• NPs had a positive impact on improving staff confidence in
  care related abilities.
• Enhanced resident and nursing knowledge of disease states
• Improved resident access to care
• Improved physician – nursing interactions
• Improved care coordination-with regard to referrals/follow up
How Can you make it Happen?

• Different Models of NP/MD Teams
  – Hired by physician
  – Hired by facility
  – Independent
• Recruitment
  – Offer precepting opportunities and clinical sites.
  – Offer mentoring opportunities post graduation
  – Salary? Versus benefits? Can you be


•   Klaasen K, Lamont L, Krishnan P. Setting a new standard of care in nursing
    homes. Can Nurse. 2009 Nov;105(9):24-30.

•   McAiney CA, Haughton D, Jennings J, Farr D, Hillier L, Morden P.A unique
    practice model for NPs in long term care homes. J Adv Nurs. 2008
•   Bourbonniere M, Mezey M, Mitty EL, Burger S, Bonner A, Bowers B, Burl JB,
    Carter D, Dimant J, Jerro SA, Reinhard SC, Ter Maat M, Nicholson NR Jr.
    Expanding the knowledge base of resident and facility outcomes of care
    delivered by APNs in LTC: Expert Panel Recommendations. Policy Politics,
    Nursing Practice. 2009;10(1), 64-70.

•   Mezey M, Burger SG, Bloom HG, Bonner A, Bourbonniere M, Bowers B, Burl
    JB, Capezuti E, Carter D, Dimant J, Jerro SA, Reinhard SC, Ter Maat M.
    Experts recommend strategies for strengthening the use of advanced practice
    nurses in nursing homes. J Am Geriatr Soc. 2005 Oct;53(10):1790-7.

•   Truscott JE. Nurse practitioners and GPs. Australian Family Physician. 2007;
    36(9): 705-707.

Implement Appropriate Staffing within
Current Budgets

           What can you do?

Staffing Plan

• Create a staffing plan
  – Build budget to support plan
  – Include budget dollars to cover call ins, in-service training,
    shift report
  – Administrator and DON responsible
  – Communicate plan and rationale to all staff
• Implement Staffing Plan
  – Create schedule according to plan
  – Involve staff in development of schedule
  – Allow flexibility in schedule for census and acuity
    fluctuations – part time, prn, on call

Schedule should not be static

Allow for real time review and adjustment !!
Ask the question -
  Do I have the right number of staff with
  appropriate skill mix and competencies
  available on this shift to care for

Monitor Staffing

• Have a system in place to regularly review adherence
  to staffing plan
   – Schedule vs. actual
   – Hours over and under budgeted levels
   – Pattern of call ins
• Continuous Improvement
   – Identify problems/ issues
   – Look for opportunities to improve
   – Develop improvement plan
• Documentation
   – Document staffing plan philosophy – do not include specific ratios
   – Document monitoring activities
   – Document reporting activities
Some ideas…

• Permanent/Consistent • Assign an acuity
  Assignments                number to each
   – Encourages familiarity, resident
    efficiency and eliminates   – Assignments would be by
    time consuming                acuity, not room number
    information gathering       – Experienced staff get
  – Staff would know              difficult residents, and
    residents daily routines      novice staff get easier

Some ideas…

• Managers work the              • Implement
  floor occasionally               “specialized” jobs
  – Find out what is not           – Bath aides
    working on the floor           – Feeding assistants
  – Find out if information is     – Light duty- answer call
    missing                          lights
  – Find out if equipment is       – Nurse assigned to new
    broken or not functioning        admission for 3 day
    appropriately                    period

Some ideas…

• Managers assigned to         • Call light answering
  monitor all meals              – Everyone in facility
  – See how the dining             accountable for
    experience is working          answering call lights
  – Attend to resident needs     – No one to walk past a
    immediately                    call light
  – Monitor resident intake      – Can make it into a game


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