Triad care team model can aid efficiency, quality
Triad care team model can aid efficiency, quality
South Carolina agency improved staff satisfaction
McLeod Home Health in Florence, SC, began restructuring efforts in fall 1999 as a result of the expected prospective payment system (PPS) and high nursing dissatisfaction.
The hospital-based agency, which covers five counties in central South Carolina, was having difficulty recruiting and retaining nurses and other staff. The agency’s nursing vacancy rate at that time was 30%. "We had two nurses hired, and both quit in orientation, saying the job was too complex, too much work," recalls administrator Lynn McCutcheon, RNC, MN, FNS. She discussed the agency’s triad care team model at the National Association for Home Care’s 19th Annual Meeting & HOMECARExpo, held Sept. 23-27 in New Orleans.
That led McCutcheon and other managers to realize the primary care nurses were experiencing role overload. Nurses already had increasing pressures, including the burden of OASIS documentation. Adding more case management responsibil- ities to their jobs only increased the stress.
Almost a third of agency’s nursing positions were unfilled. The solution was to create a triad team care model that involves three nurses who work together. The three positions are an RN case manager, an RN staff nurse, and an LPN staff nurse. Some teams may have two RN staff nurses and/or two LPN staff nurses for a total of five team members.
Since implementing the triad team care model, the agency has had a number of positive outcomes, including the following:
• Patient satisfaction rose slightly to 99.98%.
• Nurses have improved their quality in paperwork timeliness and reducing billing errors.
• The nursing vacancy rate dropped from 30% to zero, and now only about 4% of the positions remain unfilled.
• Nursing job satisfaction rose from 63% to 96%.
Here’s how the agency developed and uses the triad team care model:
1. Investigate the problem. Management began by holding staff forums to find out what the nursing staff said was wrong with their jobs. They used that information to develop and administer nurses’ job satisfaction surveys, looking for answers to what problems existed and how extensive the problems were. When the surveys showed an overall satisfaction rate of 63%, it confirmed what management already suspected: Nurses were under too much stress and had feelings of job overload. Productivity was up to seven patients a day per nurse. "When nurses were on call, they also had to carry a patient load and schedule in new referrals if they called in after hours," McCutcheon says.
Other problems were that the agency consistently had inadequate weekend coverage, and the staff had to work as efficiently as possible.
The agency held a brainstorming session to find solutions to those problems. Management asked nurses what could be done to make their jobs more manageable while maintaining agency quality and productivity. Together, management and staff came up with the idea of a team model that would provide better weekend coverage and make the nurses’ day-to-day demands less intense.
2. Structure teams to improve care quality. While McLeod Home Health managers wanted to improve staff satisfaction, they couldn’t accomplish that at the expense of quality or efficiency, so they had to come up with a coverage model that could work on all fronts.
"We had to restructure the work week," says McCutcheon. "The Monday through Friday work week will no longer meet the needs of our patient caseload or the needs of the agency."
They gave nurses three options. They could stay with the primary care model for nursing in which every nurse works every other weekend. They could move to a hospital staff model in which two nurses share a caseload, each working 12-hour shifts, with one working Monday, Wednesday, Friday, and the other working Tuesday, Thursday, Saturday. Or they could share caseload in a triad model in which the senior nursing staff would take the lead as the case managers.
The staff agreed to try the third option, and that’s how the triad model was conceptualized, McCutcheon says.
3. Define roles of team members. The triad care team model is based on having three nurses with varying degrees of training and experience work together in handling one patient caseload, including weekend coverage. Some of the teams may have four or five members, but there always is only one case manager. The team members are:
• RN case manager: The top part of the triad is the RN case manager. The agency recruits senior, experienced nurses for the case manager role. Those nurses are paid a little more and have several other incentives, including a reimbursement structure in which case managers receive bonuses as they move up the clinical ladder. "We try to recruit case managers from within the company," McCutcheon says.
Case managers handle a caseload of 60 to 75 patients, and they work Monday through Friday, although they are sometimes on call during the weekend. Their duties include scheduling for the team and conducting patient care conferences with the team. They also provide clinical coordination and outcomes management for the team’s caseload of patients. The case managers conduct the OASIS visits for the team, including recertification, resumption of care, and discharge visits, and they periodically assess the patient’s plan of care and how the patient is progressing toward the desired outcomes. They also provide clinical coordination, transfer, recertification, and discharge planning.
The RN case manager also reviews the utilization and outcomes reports assigned to each patient and can take physician calls for the team.
The average caseload is about four visits per day. Case managers also are expected to spend four hours per day on case management duties. They’re paid on a per-visit basis for patient visits and an hourly basis for case management.
• RN staff nurse: This nurse works in collaboration with the case manager. The RN staff nurse can move up the ladder to become a case manager. This position typically is filled by newer staff who have been recruited to the agency. They’re paid per visit, and they have to work every other weekend. Their productivity goal is eight visits per day.
The RN staff nurses make sure patients are moving toward their desired outcomes, and they supervise LPN staff nurses. They also conduct OASIS visits when there is some overflow from the case manager. They are paid more than the LPN staff nurses.
• LPN staff nurse: LPN staff nurses work on those weekends the RN staff nurses are not working. "In our environment, we wanted to bring in a low-cost discipline of LPN," McCutcheon says. RN nurses supervise all of the LPN nurses, so quality control can be maintained.
The LPN nurses also are paid on a per-visit basis, and their goal also is eight visits per day. They are not permitted to do admissions or conduct OASIS visits. They also cannot provide intravenous or high-tech services. Their role primarily is to provide technical skills such as dressing changes and blood draws. If they run into any problems while at a patient’s home, RNs are always on call to help out.
4. Measure outcomes. The triad model resulted in an increase in case management expense and bonus expense, but it also made use of lower-cost LPN staff and reduced recruitment costs, so the overall cost is lower in the areas of salary expense, overtime, and mileage. Pre-billing accuracy and paperwork timeliness also improved.
Another positive outcome was a consistently high patient satisfaction rating of 99.98%. Patients were pleased to have a greater continuity in their care providers. They knew they would be cared for by one member of a three- to five-nurse team, except for the initial assessment, which is done by a special admissions team.
"We introduce the model to patients and let them know which group of nurses is taking care of them and what they can expect from each member of the team," McCutcheon says. "The case manager explains the role of the nurses, and patients feel support from the team at the start."
Nursing satisfaction quickly rose because the less experienced RNs no longer were expected to balance their time between patient visits and extensive paperwork duties, and the more experienced nurses, who became case managers, were given paid office time to handle the paperwork and managerial duties. Once the nursing satisfaction rate increased from 63% to 95%, the agency had a simultaneous drop in its vacancy rate.
The agency has developed a triad scorecard in which each team is evaluated quarterly on its progress toward outcomes. The scorecard will focus on compliance — corporate, regulatory, accreditation, and clinical outcomes. The agency will collect data on utilization outcomes, including emergency room visit rates, hospital readmission rates, episode visits, and supply cost management.
5. Make continual changes in accordance with PPS. McLeod Home Health managers are working on increasing nursing visit times and implementing various pathways in accordance with the new type of pressures inherent in the PPS changes. The use of pathways should lead to faster outcomes in the area of patient education and independence, McCutcheon says.
The agency also uses the triad model for other disciplines, including physical therapy, occupational therapy, and speech-language pathology. The case management clinical ladder is used to encourage nurses to gain specialty expertise in IV care, chemotherapy, pediatrics, psychiatric care, cardiac care, and wound management.
• Lynn McCutcheon, RNC, MN, FNS, Administrator, McLeod Home Health, 1945 W. Palmetto St., Box 16, Florence, SC 29501. Telephone: (843) 669-3050. Fax: (843) 669-5368. E-mail: [email protected].
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