Use restorative care to cut cost per visit and reduce number of visits
Use restorative care to cut cost per visit and reduce number of visits
Program helps you cope with managed care's limits
The mantra of the moment in hospital-based home care is "Cut costs, do fewer visits, improve quality," but the quest to meet those demands leaves most company managers feeling as if the walls and the ceiling are closing in on them. You can stop some of that feeling with a restorative nursing care program, say home care managers who offer this service.
"If anything, I wish I had started this program sooner. The benefits to the patient and the company are enormous," says Judy Varady, RN, BSN, the nurse coordinator at SantaFe HomeCare in Gainesville, FL. SantaFe has steadily expanded its program since it started the program several years ago with just one restorative nurse. In February, Varady trained an additional 44 nurses and an equal number of aides at the company's various branches. Plans are now being considered to expand the restorative care program statewide to all of the agencies owned by SantaFe's new parent company, Shands HomeCare, also headquartered in Gainesville, FL.
SantaFe HomeCare started the restorative care program about three years ago to counter the physical therapist shortage, and soon afterward the company's nurses noticed that they rarely did Medicare and Medicaid recertifications for the therapy patients anymore.
"That's when we noticed that patients get stronger faster when both the nurses and the aides do restorative nursing. It takes almost half the time for them to regain independence," Varady says.
Home care companies also can reduce the cost of physical therapy per patient by having their physical therapists concentrate on doing initial assessments and setting up plans of care for patients, and letting their nurses and aides do the day-to-day work of helping patients do the exercises prescribed by the therapists. Nurses and aides can also free up therapists' time by doing the documentation and other paperwork necessary for therapy patients.
Operating in this manner has reduced the cost per visit at Northern Hospital Home Care in Mt. Airy, NC, by $3, says director Mary Alice Culler, RN, BSN. Visits made by the restorative nurses and aides take slightly longer, but the cost to the company in their lower productivity is made up in the savings gained by making fewer therapist visits.
This makes restorative nursing a strategic service to offer, as managed care forces home care companies to reduce their visits, and as a Medicare/Medicaid prospective payment system nears completion. The HMOs SantaFe HomeCare works with now only allow two therapy visits to total hip replacement patients and one therapy visit to total knee replacement patients, Varady says. Under Medicare, SantaFe's therapists used to visit those patients three times a week for two months.
"The therapist shortage is still there, but I'm not sure it'll continue, because HMOs are reducing therapy visits. Either way, restorative nursing will help us," Varady says.
Restorative nursing also improves the continuum of care, helping hospital-based home care companies strengthen what is already a forte for them, and giving them yet another edge over their freestanding competition, HHH sources tell. A good portion of many agencies' patients could use restorative care. Susquehanna Regional Home Health Services in Williamsport, PA, plans to expand its program; as many as one in four patients in its market have a referral for some type of therapy.
Despite all the benefits of providing restorative care, hospital-based home care companies should analyze their business before starting up a program. (See questions to ask to determine whether restorative care is right for your company, p. 54.) If you do decide to start up a restorative care program, here are some tips to help you:
* Start small, and work your way up.
Focus on one type of restorative nursing, such as helping patients who were hospitalized and bed-bound, and are now weakened and need exercises to increase their strength and endurance, says Hilda Wright, RN, BSN, the rehabilitation supervisor at Northern Hospital Home Care. This is how she started, and since then she has expanded her program to include most other types of restorative care.
* Make sure your program will fit within the boundaries of your state laws.
Write to all of the relevant state boards, including your state home care board and each board for individual therapies, to get copies of the regulations and laws affecting restorative nursing in your state, Culler advises.
Keep copies of rules
"Don't just get the information over the phone. Every provider should have copies of these rules on file. You owe it to yourself," Culler says.
Being familiar with these rules and having copies of them on hand will help you make sure that your restorative nursing program is operating within the boundaries of the rules. Armed with this information, you will also be able to answer questions from Medicare or Joint Commission on Healthcare Organizations surveyors who may not be familiar with the particular rules of your state.
Look in the Medicare Health Insurance Manual 11, sec. 234.9 for information on the Medicare restorative nursing benefit. The benefit covers exercises, transfer training, and "carrying out of a restorative program ordered by a physician."
To ensure reimbursement, physicians' orders must specify the need for restorative services in addition to any nursing services ordered. The restorative nursing treatment code should not be used by agencies when describing nonskilled services such as routine range-of-motion exercises performed with the assistance of a home health aide. Medicare also requires that agencies document that the patient is working toward established goals and is making progress.
Medicare does not require that the restorative program be established by a physical therapist, although that is permitted. The decisions about who assesses patient needs and who heads the restorative team often are made for an agency by various state medical professional practice acts. Compliance with state licensure guidelines for nurses and therapists is an essential factor in obtaining Medicare reimbursement for restorative nursing, restorative nursing managers say.
* Lobby your therapists to get their backing.
Most therapists at the home care companies HHH interviewed were reluctant to allow nurses and aides to assist patients with their exercises. The therapists feared losing business, and they didn't trust the abilities of the nurses and aides. To counter this problem, you'll need to meet privately with the therapists to explain to them that they will actually benefit from the restorative nursing program. Varady explained this by presenting her company's therapists with these facts:
-- Managed care companies don't allow many therapist visits.
-- Medicare and Medicaid will likely reduce the therapy visits allowed in the future.
-- Already Medicare and Medicaid are questioning and denying therapy visits, often after the fact.
-- The company couldn't afford many therapy visits for its charity cases anymore.
-- Patients and their families prefer to work with the nurses and aides because they see them more often and are more comfortable with them than with therapists.
-- The restorative nursing program would actually free up therapists to see a greater number of patients, though they would visit each patient less often.
"I had to explain to them that I wasn't trying to take their jobs. But you have to understand why they're feeling threatened. They've got managed care coming down on them, and they've priced themselves out of the market," Varady says.
Get therapists' input
Managers should certainly get their therapists' input on their proposed restorative nursing programs, to ensure that their program is a solid one, especially if you don't have a rehab background.
Don't be surprised if the therapists attack your training program. They're under siege from managed care at the moment, and at first they are likely to perceive restorative nursing as another threat to their territory.
"They tore my training session apart," says Varady.
Once Varady explained that restorative care would help provide a stronger continuum of care for patients, and that this would make the company more attractive to managed care companies, she gained the therapists' trust, and they were quite helpful with the program, Varady says. Now Varady's therapists are on her side, and they help her with everything in the program, including writing care plans. So far they have written care plans for four categories of restorative care:
-- bowel and bladder therapy;
-- activities of daily living (ADLs);
-- mobility;
-- dysphagia.
They plan to write additional plans for other categories of care, including aphasia. After that, the team will tackle the job of writing quality assurance tools to control whether nurses and aides are documenting patients' progress the way they should. (See sample SantaFe HomeCare restorative nursing care plan, p. 52.)
* Get backing of referring physicians.
"I can't stress enough the importance of physician participation in restorative nursing," Wright says. Referrals depend on this, she says.
She recommends talking individually with your referring physicians to get advice on how to run your program, and ultimately, to get support. The more your restorative care staff communicate with physicians, the more patient care will improve, Wright says.
* Let restorative care team members volunteer themselves.
To ensure that your restorative care staff deliver the highest quality care, let them volunteer to be on the team, restorative nursing managers say. Wright posts the positions for the staff to see and has them apply for them informally. She then gives them some background information describing what restorative nursing is, what the responsibilities of the job are, and what training they have to do.
"I tell them about all of this first, so they can make sure they really want to be on the restorative team," Wright says.
She also requires that her restorative nurses be willing to study for certification from the Association of Rehabilitation Nurses (ARN). Wright says she wants her restorative nurses to be certified by ARN to prove that they excel in this area of care.
The company pays for the nurses' preparatory materials and competency exams, and employees must pay for their transportation and lodging to the exam site.
There is no requirement that restorative nurses be certified, but Wright says it is worth the effort and expense because the certification proves to consumers and managed care organizations that the restorative nurses are top quality.
"Also, it sets you apart, as far as personal pride goes. You pass the exam, and you see all of your hard work paying off," she says.
* Don't let restorative care team think they're being given more to do.
Restorative care team members at the companies HHH interviewed aren't paid any more for doing this work, so their supervisors had to work to make them see the benefit of learning to perform restorative care duties.
"I started out by saying to them, 'You're already doing most of what we're going to teach you to do.' This is especially important with the aides. If the aides feel you're supporting them and affirming what they're already doing, they'll do this no problem," Varady says.
* Make the restorative care staff one team.
Many hospital-based home care companies have created geographic teams of nurses and aides to improve productivity. If you do this at your company, consider having your restorative care staff operate as its own separate team, for communication purposes.
After several years of having two geographic restorative care teams, SantaFe HomeCare changed this system in September 1995, to having one big restorative care team.
This doesn't mean that the restorative care staff can't also serve on the geographic teams. It just means that communication between the restorative nurses and aides must cross the lines of the geographic teams.
"We just realized that it has to be done this way for communication continuity to happen," Varady says.
With two teams, all new patients were admitted in the same way, and patients with therapy referrals had to be assigned restorative nurses and aides. Under that system, the restorative care team had a hard time finding out about all patients who needed restorative care.
Now, any patient with a referral for any type of therapy is admitted by a restorative nurse. This way, Varady's restorative nurses are aware of all the therapy patients, no one slips through the cracks, and communication about patients occurs faster.
* Make referral sources aware of your restorative team.
The marketing and community awareness activities you'll need to do for your restorative nursing program aren't any different from the marketing you do for all your other services. Talk with doctors and their office staff, hospital nurses, and hospital discharge staff, restorative care managers say.
"We do all that, and we rely on word of mouth, and on advertising on radio and in newspapers. We recently did brochures with photos of our nurses in them. You just have to do it all," says Marcy Rothfuss, BSN, CRRN, the rehabilitative manager at Susquehanna Regional Home Health Services in Williamsport, PA.
Document patients' progress
* Use home health aides to document patients' progress.
A crucial element in restorative care is documenting patients' progress toward independence. Therapists and restorative nurses can assess patients better if the restorative home health aides, who see patients more often than the nurses, document how well patients perform the therapists' exercise plans, SantaFe HomeCare has found.
Varady asked her restorative nursing team to help her create a documentation tool for the home health aides to use. They ended up with a one-page flow sheet that asks aides to record how well patients bathe, dress, walk and perform their exercises, using a table of percentages that guides the aides in stating what patients do. The tool is printed on noncarbon, two-copy paper.
The aides put one copy of the completed documents in patients' folders in their homes, and the aides file the other copy of the tool in the patients' chart in the office. (See SantaFe HomeCare aide assignment rehab flow sheet, enclosed.)
Improve aides' training
"In home health we often underestimate our aides. We need to train them more extensively to help us monitor patient progress. They can easily tell us things like, 'The patient isn't doing what you told me they're supposed to do.' We just have to train them to see when a patient is doing well or not," Culler says.
At Susquehanna Regional Home Health Services, the restorative care aides are taught to observe patients' functional ability and to record it in detail, so that the nurse and the therapist can read the aide's notes and see what the patient did. For example, Rothfuss teaches the aides to note something like the fact that a patient walked 15 feet independently last week, and 20 feet this week. Or they might document that a patient's plan of care called for him to lift his leg and rotate his ankle while sitting on his bed, but the patient had to rest after doing two repetitions, and that after that he wasn't able to elevate his leg all the way.
"Mostly aides need to learn how to record patients' progress, and to help and encourage patients to do their exercises," Rothfuss says. *
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