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
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
• Resident/Patient needs
• Staff preferences
• Family preferences
Clinical Support for Rising Acuity
• Clinical Professionals
– Nurses - RN and APRN
– MD, Podiatry, Optometry
– 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
• 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
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
• 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
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
*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
• Decreased medication errors
• Improved assessment and early recognition
• 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
• 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
– 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;
Implement Appropriate Staffing within
What can you do?
• Create a staffing plan
– Build budget to support plan
– Include budget dollars to cover call ins, in-service training,
– 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
• 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
– Document staffing plan philosophy – do not include specific ratios
– Document monitoring activities
– Document reporting activities
• 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
• 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
– Find out if equipment is – Nurse assigned to new
broken or not functioning admission for 3 day
• 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