IMPACT OF DRG’S ON NURSING REPORT OF THE WESTERN INSTITUTE OF NURSING U.S. DEPARTMENT OF HEALTH 6 HUMAN SERVICES Public Health Service Health Resources and Services Administration /ir:‘at gr LIE? CALIF‘ / "u-{% r” l l UNiVETl Ti fl' OF / / QRH l A .W/ HEALTH RESOURCES AND SERVICES ADMINISTRATION “HRSA—Helping Build A Healthier Nation” The Health Resources and Services Administration has leadership responsibility in the US. Public Health Service for health service and resource is- sues. HRSA pursues its objectives by: - Supporting states and communities in delivering health care to underserved residents, mothers and children and other groups; 0 Participating in the campaign against AIDS; - Serving as a focal point for federal organ trans- plant activities; 0 Providing leadership in improving health profes- sions training; - Tracking the supply of health professionals and monitoring their competence through operation of a nationwide data bank on malpractice claims and sanctions; and - Monitoring developments affecting health facil- ities, especially those in rural areas. NOV IMPACT OF DRG'S ON NURSING REPORT OF THE WESTERN INSTITUTE 'OF NURSING US. DEPARTMENT OF HEALTH 6 HUMAN SERVICES Public Health Service Health Resources and Services Administration Bureau of Health Professions Division of Nursing 0.3. DEPOSITORY JUL 2? I988 5W6} 300x PUBL This report was prepared under purchase order number HRSA 87-338(P) from the Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human ServiCes. Division of Nursing Project Officer is Mary S. Hill, RN, PhD, Chief, Nursing Education Branch- This report was prepared by: Jeanne M. Kearns This document is for sale by the National Technical Information Service, 5285 Port Royal Road, Springfield, VA 22161. Accession number: HRP-0907l79- Issued: July 1988. ' ii NW7! FOREWORD Cost containment efforts in the reimbursement of health facilities underip 0,? L“ the prospective payment system have contributed to changes in the “ 9 responsibilities and role of the nurse providing clinical care to patients. However, accurate data have not been available to assess the impact these changes were making on nursing practice and the subsequent implications for undergraduate nursing education. In an effort to obtain the needed data the Division of Nursing undertook a major project with four regional professional nursing organizations. A ‘ panel of experts from each region met at an invitational conference to I) examine the impact that the implementation of diagnosis related groups in the reimbursement of hospitals and community settings has had on clincal 'nursing care in the region and, 2) to examine the implications of any changes for undergraduate nursing education, especially in the clinical area. The four regional reports, containing monographs submitted by leading nurse scholars within each region and the conclusions and recommendations of the panels, are presented in separate publications. They are available for purchase from the National Technical Information Service (5285 Port Royal Road, Springfield, Virginia 22161) under the following titles and accession numbers: Impact of DRGs on Nursing: Report of the Mid—Atlantic Regional Nursing Association (HEP—0907180) Impact of DRGs on Nursing: Report of the Midwest Alliance in Nursing, Inc. (HEP-0907178) Impact of DRGs on Nursing: Report of the Southern Regional Education Board (HRP-0907181) Impact of DRGs on Nursing: Report of the Western Institute of Nursing (HEP-0907179) Through examining current clinical practice and proposing patterns for ‘changes in nursing education, the work of the regional groups will have far reaching benefits for both users and providers of nursing care services. Division of Nursing iii TABLE OF CONTENTS introduction ........................ 1 Papers ......... ‘ .................. 4 l Acute Care Nursing: Impact of DRGs ‘ Malinda Mitchell and Suzanne Dibble ............ 5 Nursing Care Requirements in Long-Term Care Revisited \ Sr. Lucia Gamroth .................... 32 r The Impact of Hospital DRGs on Nursing Care ‘ in Community Health Settings Dorothy Kleffel ..................... 43 ‘ Impact of DRGs on Undergraduate Nursing Curriculum Carol A. Lindeman .................... 70 The Questionnaires: Nursing Practice and Nursing Education .......... 97 l‘ieport of the Panel of Experts Meeting ........... 128 Appendix A: List of Participants .............. 142 Appendix B: Agenda .................... 144 J L 523m. INTRODUCTION The four regional nursing organizations‘ received a procurement from the Division of Nursing, Bureau of Health Professions, Department of I-lealth and Human services to carry out a project to study the impact of diagnostic-related groups (DRGs) on nursing care. As stated in the p‘roposal, the purpose of the procurement was to "secure information cbncerning the impact of the Prospective Payment System (DRGs) in the reimbursement of hospitals, on clinical nursing care both in hospital and community settings. Implications for modification of undergraduate clinical \ and didactic nursing undergraduate courses were to be identified.” ‘ The executive directors of the regional nursing organizations met with the project officer in June 1987. They discussed the scope of the project and determined that the impact on long-term care facilities should be considered as well as that on hospitals. Thus, the term institutions would be used rather than hospitals. For the purposes of this study, undergraduate programs were defined as those that lead to initial li¢ensure. Consistent with the tasks as outlined by the Division of Nursing, the I Western Institute of Nursing selected three experts to prepare monographs, ch focusing on a specific topic, and convened a panel of experts. The ea 1 These organizations are the Mid-Atlantic Regional Nursing A sociation (MARNA), the Midwest Alliance in Nursing (MAIN), the So thern Regional Education Board (SREB), and the Western Institute of} Nursing(WIN). experts selected for the western region were: Malinda Mitchell, Associate Hospital Director/Director of Nursing at Stanford University Hospital, Stanford, California, who prepared the monograph ”Acute Care Nursing: Impact of DRGs." Dorothy KIeffeI, Director of Education and Research at The Visiting Nurse Foundation, Inc., Los Angeles, California, who prepared the monograph "The Impact of Hospital DRGs on Nursing Care in Community Health Settings." Carol Lindeman, Dean of the School of Nursing and Associate Director of Nursing Service at The Oregon Health Sciences University, Portland, Oregon, who prepared the monograph ”Impact of DRGs on Undergraduate Nursing Curriculum.” These papers, which were sent to panel members prior to the meeting, served as the focal point for the panel members’ deliberations at the meeting. In addition, to provide information related to long-term care facilities, Sr. Lucia Gamroth, Acting Director of the Benedictine Institute for Long Term Care in Mt. Angel, Oregon, presented her study, ”Nursing Care Requirements in Long Term Care Revisited," at the panel meeting; To obtain regional specific data on the perceived influence of DRGs' on nursing education programs and on nursing practices, questionnaires were sent to schools of nursing and health care agencies in the West. The data from the questionnaires were analyzed and a summary of the res lts was sent to the panel members prior to the meeting. The results wer then discussed at the meeting. The panel of experts that met in Denver, Colorado, November 10-11, 1981 , included representatives from associate and baccalaureate degree pro rams, acute and long-term care institutions, and community health settings. In addition to the panel members, a Division of Nursing representative, two guests, and three WIN staff members participated. The par icipants of this WIN meeting are listed in Appendix A. The agenda pre ared for the meeting is presented in Appendix B. At the meeting, Malinda Mitchell, Dorothy Kleffel, and Carol Lin‘ eman each presented highlights from the prepared papers. Sr. Lucia Ga ‘ roth presented her study, and Jeanne M. Kcarns, executive director of WIN, presented the questionnaire reSults. Each of the panelists shared information obtained from colleagues regarding the impact of DRGs on pra tice and education. The panelists discussed the issues and trends and made recommendations for undergraduate nursing education and for other studies. The next sections of this report include the three monographs, the rep rt 01‘ the study on long-term care, and the results from the questionnaires. The final section includes the report of the panel of experts meeting. PAPERS The following section includes the papers addressing the impact of DRGs on clinical nursing care in hospitals, long-term care settings, and community settings, and the implications for undergraduate nursing curricula. The papers by Mitchell, Kleffel, and Lindeman were distributed prior to the meeting. The Gamroth paper was presented at the meeting. ACUTE CARE NURSING: IMPACT OF DRGs Malinda Mitchell, RN, MS Associate Hospital Director Director of Nursing Stanford University Hospital Suzanne Dibble, DNSc, RN Nurse Researcher Stanford University Hospital On April 20, 1983, when President Reagan signed into law H.R. 1900 (PL. 98-21), the Social Security Amendments of 1983, a new era in health ca e financing was begun. Under the prospective payment system (PPS), a holpital is paid a preset price for each Medicare inpatient case based on th patient’s Diagnosis Related Group (DRG). The purpose of this paper is to iscuss the anticipated and actual impact of PPS on nursing in an acute ca e setting. ”However, before describing the specific nursing impact, DJGs must first be defined in the sociopolitical context of their coTeption and implementation. Rising Health Care Costs When the Medicare and Medicaid programs were created during the 19 0s, it was a time of robust economic growth in the United States; total he lth care spending represented about 6 percent of the Gross National Pr duct (GNP) (Davis, 1983a). By 1981, this percentage had risen to over 10 ercent, or $287 billion (Davis, 1983a), and in 1982, spending for health car in the United States had risen to $322 billion (Davis, 1984). One cmgd speculate about the actual percentage of the GNP that would be an appropriate representation of adequate health care for the citizens of the United States. However, it is not the actual percentage that is significant, but the financial base that supports that percentage. If the pace of increased expenditures had continued, the Hospital Insurance Trust Fund, which supports the Medicare program,.would have faced insolvency by 1990 (Davis, 1984). The historical development of the proposed solutions for this issue is an example of an approach to problem solving that is concrete and specific. The proposed solutions were related to financing rather than a method that would attempt to address the issues in a broader sociopolitical context. It is also an example of how a system intended for use in one situation was adopted for another, used as a demonstration project, and finally codified into law. The New Jersey Experience Widespread interest became focused on the New Jersey method of looking at cost in terms of patient-related variables. This methodology was originally developed by a research team that included Professor John Thompson, R.N., from Yale University. The purpose of their original work was "a definition of case types, each of which could be expected to receive similar outputs or services from a hospital" (Fetter, Shin, Freeman, Averill, & Thompson, 1980, p. 5). The basis for appraising patients was a series of 83 Major Diagnostic Categories (MDC) and 383 DRGs that grouped patients according to primary diagnoses, secondary diagnoses, surgery, age, and complications. New Jersey adapted and refined the 1 . categories to 23 MDCs with 467 DRGs. ”Given the capacity of the DRG syitem to predict and quantify hospital resource use and the relationship ofiresource use to cost, it was natural to effect a marriage between DRGs and reimbursement" (Joel, 1983, p. 560). Shaffer (1983) has carefully explicated the political and historical perspective of the New Jersey experience with prospective payment, and this will not be repeated here. Legislative Background The first attempt to control hospital costs was managed by reducing the number of days of hospitalization via utilization review through a professional standards review organization (PRSO). There were no sanctions, and the expenditures were not significantly reduced. Another method employed was the approval of capital expenditures through a Certificate of Need. Again,'the outcome was more annoying then effLsctive. The third method for controlling costs was one that determines and limits the amounts that hospitals would receive for the services they provide (Schwartz, 1981). ”In 1978, HCFA [Health Care Financing Administration] contracted with Abt Associates to conduct the National Hospital Rate Setting Study to evaiuate in depth the prospective payments systems in Arizona, Corinecticut, Maryland, Massachusetts, Minnesota, New Jersey, New York, Wasrington, and western Pennsylvania" (Davis, 1983b, p. 99). Preliminary reports were published in 1981 indicating that mandatory rate setting was efchtive in controlling hospital costs (Davis, 1983b). Congress then passed 1 the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA). Among its provisions, this law (1) established per-case caps for hospital reimbursement under the existing retrospective system and (2) required HCFA to develop a proposal for a prospective nationwide payment system (Lewis, 1984). In 1982, HFCA, through the Department of Health and Human Services (DHHS) Secretary, presented Congress with an extensive report outlining a prospective payment system for Medicare (Davis, 1983b). Congress moved even more quickly than expected and passed prospective payment legislation in March of 1983. The New Payment System The program began nationwide with each hospital’s first accounting period on or after October I, 1983. Medicare payments for inpatient operating costs were fixed based on 467 DRGs. Consequently, each hospital had to ascertain the best method of merging financial data with clinical data from the medical record in order to receive reimbursement for their Medicare admissions (Lichtig, 1982). Modifications to the payments occurred due to the location of the hospital (rural versus urban) as well as the region of the country. Provisions were also made for atypical cases (outliers), teaching expenses, and inflation. The program was phased in over a three-year period. The Prospective Payment Assessment Commission (ProPAC) was established to advise Congress and the secretary of the DHHS regarding changes in hospital reimbursement and revisions to the DRG classification system. Young (1984) has delineated the structure and focus of ProPAC and has asked for ”assistance from the nursing community in defining prospective payment issues relative to nursing, in determining the availability and content of data source, and in identifying nursing research currently being conducted related to prospective payment and the DRG classification system” (p. 211). Anticipated Impact on Nursing The nation's nurses had their first glimmer of the impact on nursing of the DRG system from their colleagues in New Jersey. Micheletti and Toth (1981) shared their concerns about set nursing salary increments under the DiiG system, potential lower levels of nurse staffing, job dissatisfaction, increased turnover, and the inability to attract new nurses. Grimaldi (1982) wrote that nurses were leaving nursing for more lucrative positions. Joel (1983, 1984) has written extensively on the impact of DRGs on nursing. She wrote about the ”rape of the nursing budget” through decreased staffing (Joel, 1983, p. 561). Out of that already stressed re- source, only 62 percent of the nursing budget went to support nursing ac- tivities; the rest was used to subsidize non-nursing activities (Joel, 1983). Joel suggested that these changes have occurred because nursing service could not be quantified. RIMS (Relative Intensity Measures) were proposed as a means to quantify nursing’s contribution to patient care within the V hospital setting. It was proposed that both DRGs and RIMs could be used in the reimbursement calculations (Joel, 1983, 1984). Toth (1984) has challenged nursing to make the DRG system work for our benefit. Other nurses reacted to the legislation and/or the experience in New Jersey by forecasting both benefits and disadvantages for nursing with the implementation of prospective payment. Some nurses predicted positive outcomes for nursing: increased staffing efficiency (Shaffer, 1984b), better chart maintenance (Shaffer, l984b), the development of a database for managing nursing resources (Halloran & Kiley, 1984), less non-nursing functions to perform (Hamilton, 1984) with increased use of ancillary services (Shaffer, l984b), growth in the utilization of computers (Hamilton, 1984; O'Connor, 1984; Shaffer, 1984a; Shaffer, 1984b), decentralization of nursing administration with education being provided at the unit level (Shaffer, 1984a) and an increased focus on discharge planning (Davis, 1984; Hamilton, 1984; O’Connor, 1984). Consequences of the DRG system were also predicted, which were perceived as negative because they would not advance the profession of nursing. Maraldo (1983) wrote that "nurses will indeed have to fight for their professional lives in many instances in the new system" (p. 2). Many predicted a reduced downward skill substitution, i.e., the utilization of LVNs instead of RNs (Maraldo, I983; Shaffer, 1984; Spitzer, 1983). Curtin (1984) and Shaffer (1984a) predicted some lost positions; drastic cuts were anticipated in nursing budgets (Maraldo, 1983). In summary, changes from the DRG system were anticipated to impact nursing in three major areas: (1) financial, (2) managerial, and (3) nursing practice. In the financial arena, the nursing budgets of hospitals with Medicare patients were expected to be cut in response to the decreased 10 subsidy. The form that those cuts would assume was unclear--they might have included the expectation of substitution of LVN positions for the current RN positions. A decreased number of resources could have adversely affected the ability of hospitals to negotiate with nurses under union contracts. In the managerial arena, nursing administrators were concerned that they might experience disproportionate cuts in the resources allotted to the nursing department. Some administrators had begun to develop and implement proposals to cost out nursing care, for a recognition of nursing’s contribution to the hospital’s mission and resources, as well as to demonstrate the need for increased monies. The "cut-and-dried" approach to reimbursement under DRGs was perceived as a threat to nursing autonomy as well as a concern about actual resource allocation. Concerns about nursing practice under the DRG system were diffused and represented a rainbow of issues. Theseincluded the demise of primary nursing, modified staffing systems, and concerns about staff as well as patient education. Implementation of DRGs The PPS for Medicare patients was initiated with the first accounting period on or after October 1, 1983. The system was phased in over a three-year period as follows: " During the first year, payment for service to Medicare patients were: 11 75% of the hospital-specific cost-per-case amount PLUS 25% of the regional average price for the patient’s DRG (Grimaldi, 1984) " During the second year. payment for service to Medicare patients t C were: 50% of the hospital-specific cost-per-case amount PLUS 37.5% of the regional average price for the patient’s DRG PLUS I 12.5% of the national average price for the patient’s DRG (Grimaldi, 1984) During the third year, payment for service to Medicare patients were: 25% of the hospital-specific cost-per-case amount PLUS 37.5% of the regional average price for the patient’s DRG PLUS 37.5% of the national average price for the patient's DRG (Department of Health and Human Services, 1983) In the fourth year, beginning on or after October 1, 1986, payments were based on the national average price for each DRG, adjusted for differences in area wages and urban vs. rural locality (Department of Health and Human Services, 1983). 12 Evaluation of these changes was mandated by the initial legislation. The forum for evaluating the efficacy of reimbursement based on DRGs was the Prospective Payment Assessment Commission (ProPAC). One agenda for the commission is the consideration of nursing care because the "law specifically states that the level of professional nursing required to maintain quality care is to be evaluated” '(Young, 1984, pp. 310-3“). Although various systems have been introduced that might reflect the nursing component of hospitalization for a Medicare recipient, currently none have achieved broad acceptance; therefore, none have been recommended for implementation by ProPAC. The actual implementation of the PPS within each hospital was accomplished through the meshing of financial with clinical data. Nurse administrators and financial officers, as well as physicians, determined the impact of DRGs on their hospital. Systems were developed to track length of stay, which built on the PSRO model. Computers were extensively employed to assist in data gathering. Physicians and nurses were implored to improve their record keeping; financial and personnel resources were poured into medical records departments to ensure maximum reimbursement potential. Care was transferred to outpatient services whenever possible. Everything was scrutinized from the statement of the hospital's mission to each FTE, capital expenditure, and ongoing program. Both the hospital and the public became aware of the impact of DRGs. 13 Impact on Staff Nursing The advent of DRGs and other concurrent changes in the competitive health care environment have resulted in numerous changes for the nurse in the acute care setting. These changes include alterations in the length of stay and acuity of patients, a shift to outpatient care, a reallocation of ancillary service and support roles, major emphasis on cost of care delivered, and an increasing need for documentation, as well as great fluctuations in patient volumes across specialties. These changes have all affected the staff nurse in the acute care setting. Decreased Lengths of Stay One of the most important changes has been the plummeting length of stay (LOS) for hospitalized patients (Newman & Autio, 1986; Miller, 1987). A trend for a decreasing LOS had begun prior to the advent of , DRGs with the national LOS decreasing from 7.6 days in 1982, to 7 days in 1983, and 6.7 days in 1984 (Levin-Epstein & Sala, 1985). The continuation of a decreased LOS is even more remarkable when one considers that now many patients are not even admitted. These trends have resulted in a "quicker yet sicker" patient population (Kramer & Schmalenberg, 1987a). Patients are admitted for a shorter length of time and are sicker during their. hospitalization and when they are discharged (Kramer & Schmalenberg, 1987b). Tia—us, the intensity of nursing care has increased because the same amount of teaching and care must now be condensed into a much shorter time frame. 14 2f; For the staff nurse the impact of the decreased LOS is experienced in two ways: (1) the increased activity associated with patients that are all in an acute phase of their illness, and (2) the emphasis on early discharge with the need for rapid discharge planning. Increased intensity. The Prospective Payment System, along with the emergence of pre-hospital review arrangements/organizations, have eliminated the hospital admission of patients that could be treated as outpatients or who were not deemed sick enough to warrant an acute care admission. This step, coupled with incentives or review processes to decrease the length of stay, has resulted in patients being hospitalized only during the acute phase of their illness. The average acuity of all patients has therefore increased on patient care units. This results in assignments for staff nurses that include only acutely ill patients. fiThere are no preoperative/preprocedure patients and no convalescing patients that are less acute.=erll patients have urgent or emergent needs, and the activities for every patient are intense and fast- paced. The balance that less acute patients brought to a nurse’s assignment no longer exists. xThis makes prioritization of activities more difficult for the nurse, as every patient has urgent needs that appear to be a top priority. Increased acuity is felt in all stages of the nursing process. Assessment is complex. Many patients are no longer admitted the night before major operative and diagnostic procedures. ,The first assessment by nursing is often post-operative or post-procedure. There is little time for 15 baseline assessments before the event. When entering the hospital the day of the procedure, all of the patient’s assessment and preparation must be done rapidly in a very short period of time. For early morning procedures, this is often preceded by the patient waking very early and traveling from home to the hospital, leaving the patient anything but rested and calm before the procedure. Early discharge. Another aspect of the decreased LOS that affects acute care nursing is the emphasis on early discharge and discharge planning (Schneidman, Griffiths, & Beblock, 1986). It is expected that all health team members will work collaboratively to minimize the LOS for each patient. The responsibility for coordinating the team’s approach to an individual patient’s care is usually given to nursing. This is best handled when a primary nurse with 24-hour accountability or a nursing case manager is assigned to the patient. This nurse must understand the expected or "normal" progression expected of a patient with a specific diagnosis. As in the past, goals must be set with the patient, but now they must be set with time frames that meet the norm for that patient’s DRG. The nurse must continually coordinate and deliver care so that there are no avoidable delays or complications that would extend the LOS. Anticipation of needs and fast responses to problems are paramount in the current environment. This type of planning is also more difficult in an environment where many nurses work part-time and continuity is an iSsue. Earlier discharges result in patients leaving the hospital in more fragile conditions. Referrals to community resources and support systems 16 have dramatically increased; therefore, the staff nurse‘s knowledge must keep pace with the evolution of these resources in the community. Many hospitals now provide (or are affiliated with) home care programs that deliver acute care in the home. It is not uncommon for the hospital nurse to prepare a patient for discharge with I.V. chemotherapy, I.V. antibiotics, a ventilator, or any number of other sophisticated therapies. In addition, for the elderly patient there has been an increasing need for better and earlier assessment of functional status. The need for early discharge requires the nurse to evaluate the functional status of the elderly prior to or on admission, so that steps can be taken to prevent any deterioration in the patient’s ability to function. When the illness itself has caused a change in functional status, planning begins immediately to restore it as quickly as possible to the pre-illness state. For all patients, the decreased LOS has left little time for teaching. The teaching that is accomplished often has to be done with family members because the patient is often too sick or not ready to retain what is taught in the hospital (Kramer & Schmalenberg, 1987b). This can be very frustrating to the acute care nurse who places a high value on teaching and derives a great deal of satisfaction from it. Shifting Roles in the Acute Care Settings The roles of many caregivers have changed since the PPS went into effect. Some have changed because of the increasing acuity and others as a result of cost reduction strategies. Many hospitals have reported 17 increased ratios of RN‘s to LVN’s and NA's (Kramer & Schmalenberg, 1987b). In fact, a panel of experts has predicted that the LVN would be phased out over the coming years (Kearns, I987). The RN has emerged as the most versatile of care providers in the acute care setting (Aiken & Mullinix, 1987) because the idle time of the less skilled staff increased as acuity increased. Many hospitals have moved to either all RN staffs, or to the use of NA’s in the role of assistant to the RN, or the unit rather than as team members with patient care assignments. This places an increased workload on the staff nurse with less ancillary staff assistance to accomplish all of the patient care requirements. In addition, ancillary staff in other departments have been reduced in many acute care hospitals during cost reduction efforts. In the professional departments there have been shifts of some aspects of care to nursing. The most common have been in respiratory therapy, physical therapy, pharmacy, dietary, and social service. Activities that years ago were performed by nurses exclusively, such as oxygen therapy, IPPB treatments, gait training, and dietary teaching, had been "taken over" by personnel in other departments, but are now being returned to nursing. However, the skills required for these activities must now be learned by nurses after years of having them performed by other departments. In addition, specialized nursing roles, such as diabetic teacher, IV nurse, or colostomy caregiver, have also been returned to the staff nurse (Schneidman, Griffiths, & Beblock, 1986). Many support departments have also cut back employees so there are 18 fewer people to carry out the non-professional tasks in the hospital. Housekeeping and clerical are not always performed at previous levels. Nurses often find themselves picking up some of these duties by default when there is no one else to do them. In addition, the use of volunteers has increased to carry out patient unit activities, and the nurse must learn how to use non-paid staff to the greatest advantage while motivating them to return on a routine basis to give assistance (Beckham, 1983). Increased Outpatient Services Hospitals have responded to the PPS by increasing their involvement in outpatient services. In the past, acute care institutions were thought of synonymously with inpatient care. Today a nurse working in an acute care hospital could be working in an outpatient setting as easily as one for inpatients. The most common outpatient services‘are ambulatory surgery, day treatment programs, diagnostic center. and home care. The hospital-based ambulatory surgery programs are competing heavily with free-standing ambulatory surgery centers. Nurses in ambulatory surgery settings usually have to be flexible enough to care for patients during pre-operative assessment and preparation for surgery as well as during the operative procedure and through the recovery process. Telephone follow-up to patients the day after their procedure is also done frequently by the same group of nurses. Because ambulatory surgery departments/centers must run very efficiently to keep costs (and therefore prices) low, nurses may need to be cross trained in all aspects of care for 19 these patients. This is much different than the traditional specialized roles for hospital nurses in the operating‘room, recovery room, or surgical unit. They must also develop systems and methods for accomplishing all of this in short time frames for patients of all ages with increasingly high- risk surgical procedures. In addition to changes in surgical outpatient care, medical care has adjusted to the advent of PPS. Day treatment programs are the medical version of the ambulatory surgery program. In these programs patients come for treatments that have previously been given during an inpatient admission. These treatments include IV antibiotic therapy, blood transfusions, IV chemotherapy, etc. These patients usually come for treatment on a repetitive basis for the duration of a specific treatment regime or over longer periods of time for treatment of chronic illnesses. Nurses must assess these patients, their responses to therapy. and their ability to cope with their illness given existing family support and community resources. Arrangements for follow-up care and any necessary community services must be accomplished by nurses who are skilled in delivering the acute care interventions and at the same time are knowledgeable and capable of planning the patient’s care as an outpatient. Diagnostic and therapy centers are another form of outpatient care provided by acute care hospitals. In these centers, diagnostic procedures that were once done only on inpatients are now routinely done for people who are not admitted to the hospital. The most common diagnostic workups include endoscopies, bronchoscopies, arteriograms, and mylograms. 20 In addition, new therapies that can be performed without an overnight stay are handled in these centers including lithotripsy for kidney and gallbladder stones. The entry of acute care hospitals into home care has produced requirements for nurses that are similar to those in day treatment programs. Nurses must be able to perform many acute care procedures and treatments in a setting that traditionally was very limited in the extent of acute care delivered. As patients have returned home with sophisticated equipment (respirators, IV pumps, etc.) and therapies (IV chemotherapy, hyperalimentation, IV antibiotics, etc.), it has been necessary to use acute care nurses for the delivery of home care. Nurses in hospitals with home care programs may have the opportunity to follow their patients in their home after discharge. The acute care skill level needed "in all the subspecialities in home care often requires that nurses work in both the inpatient setting and the home care setting to maintain, expand, and update their skills. Increased Cost Consciousness The implementation of DRGs has produced substantial changes in what is considered appropriate behavior for hospital personnel. Nurses on patient'care units are expected to participate in identifying and implementing cost containment measures. Authors in the popular nursing literature have written that the staff nurse should ”avoid waste“ (RN, 1986), delegate non-nursing tasks (Piper, 1985; Smith, 1985; RN, 1986). 21 identify less expensive substitutes that can be used without compromising quality (RN, 1986), fine tune the unit routine in order that the diagnostic and treatment regimen is accomplished expeditiously (Joel, 1987), reduce the use of costly supplies (Piper, 1985; Joel, 1987), collaborate with other departments to see that the patient’s needs are quickly met (Smith, 1985), teach self-care early (Piper, 1985), look for ways to save time (Piper, 1985), and collaborate with physicians in planning and implementing care (O’Leary, 1985). Cost consciousness has seldom been included in either basic or advanced nursing education. It is important to note that these new demands on staff nurses for cost consciousness and cost-effective practice are in addition to the increased patient acuity and shortened LOS previously discussed. Dealing with cost issues has become an expected part of the staff nurse role. r'It affects the independent practice of nursing (e.g., concerns Y around nursing diagnoses, care planning and follow-up), and a major impact has been noted on the dependent practice of nursing, namely, that, practice that is under the direction of the patient’s physician. The nurse’s close relationship with physicians in the delivery of inpatient care may result in the evaluation of physician practice patterns. In some hospitals, this has become almost a "policing" role, for example, reporting physicians who utilize more resources than others, whereas in other institutions a more collaborative approach between physicians and nurses has evolved. These efforts have resulted in a case management approach in one hospital where the LOS is reduced through standardization of both medical and nursing 22 care for the patient through the use of "critical pathways" (Woldum, 1987). In another study the LOS was significantly decreased for patients undergoing hip replacements through increased clinician awareness of costs and early discharge planning (Weiss, Sheridan, Sommers, Kirkwood, & Silverman, 1987). Physician orders have come under close, scrutiny. For example, the routine order for "vital signs q.4h" can be viewed as using , valuable nursing resources indiscriminately. When nurses and physicians plan together, resources may be potentially utilized more effectively. Thus, a collaborative approach to cost-effective patient care is a vital link to preserving quality in the health care system. When any form of rationing of resources occurs, both ethical and legal dilemmas surface. Creighton (1985) has outlined the legal implications of DRGs for nurses as caregivers and writes that the actual impact will be known only as cases are settled through the court system.- Issues are raised toady surrounding the ethical allocation of scarce resources. .Veatch (1986) suggests that "clinicians should not participate in deciding who should get less care but should remain committed to their patients’ interests" (p. 32). As a theoretical statement, this suggestion has merit. However, often the nurse at the bedside does not have the luxury of "not participating in the decision," because it is that nurse’s responsibility to prioritize resources in terms of nursing time and patient needs. Technology and cost management have increased this burden for the staff nurse. Science and justice become more difficult in a mode of scarcity. 23 Quality Assurance In the beginning years after PPS was initiated, emphasis was placed almost entirely on cost and reimbursement (Curtin, 1983; McKibbin, Brimmer, Galliher, Hartley, & Clinton, 1985; Mowry & Korpman, 1985; Reschak, Biordi, Holm, & Santucci, 1985; Shaffer, 1985; Fosbinder, 1986; McCormick, 1986; Shafer, Frauenthal, & Tower, 1987). Although there were some provisions that addressed quality of care, they tended to be couched in general terms. More recently the interest in quality of care haslsurfaced in two areas: (1) the quality of clinical outcomes and (2) the level of patient satisfaction with the service aspects of their care. Clinical outcomes are being scrutinized, partially because of efforts to bring to the public eye concerns about a "two-tiered” health care system. Allegations have been made that patients who are insured under the Medicare system are being discharged too soon, and that they are receiving less than optimal care (Champlin, I985; Staff Report, 1985). Monitoring clinical outcomes is one way to provide data to answer the quality questions. The cost-quality equation represents a ratio between quality and cost. Questions about this equation are being posed by professionals and consumers alike. Consumers expect to find out the level of quality care they will receive for a given price. The very system that created numbers of empty hospital beds has also fostered competition to fill those beds. Many hospitals now have marketing departments to attract potential patients to consider their services. A way to differentiate one facility from another is to describe 24 the level of care given in their facility, and reference the ”quality" of that care. A measure of success of the marketing effort is reflected not only in numbers (census), but also in customer (patient) satisfaction. The interest in the patient’s perception of the quality of care has brought about a real service orientation to hospitals. The competitive environment that has emerged in health care has forced hospital management to look at how the patients are treated. ”Guest Relations” programs have been embraced by many institutions to effect a consumer focus on employees. These programs are usually accompanied by patient satisfaction surveys that encourage patients to give feedback about all aspects of their hospitalization including nursing care. The burden then rests with the managers and staff to analyze the data, making adjustments and changes in their delivery of nursing care where appropriate. In the examples above, those related to clinical outcome and patient satisfaction both require an agreement about the definition of quality care, as well as the means to measure it. Standards of care can provide the basis for defining quality care. Standards articulated by professional organizations such as ANA, AAP, and NAACOG are sources of information about the definition of quality care. Nursing departments use these to set standards and outcome measures for specific services or DRGs in their hospital (Woldum, 1987). Knowledge of standards and use of standardized » care plans as guides to patient care will be a continuing responsibility of staff nurses. 25 Documentation Documentation of the care given continues to be the industry standard for the determination of what has actually happened in the patient/professional interactions. Reimbursement is determined by chart audit; consequently, if care was given and not charted, no reimbursement will be forthcoming (Rutkowski, 1985). Computerization of documentation is increasing in order to capture the large amounts of information needed about each patient to do analyses of the process and outcome of patient care. An additional bonus in computerized documentation systems is their ability to free the nurse from the manual task of repetitive written documentation and allow more time for direct patient care. Fluctuating Census One phenomenon that has accompanied the ‘Prospective Payment System is the dramatic fluctuations in numbers of patients being hospitalized. Although the causes are not clearly understood, the impact has resulted in great difficulty, especially for nursing. Early census declines continue for some hospitals, whereas others have experienced rebounds above prior census levels. However, even for those hospitals with a stable or increased average census, the daily variability in volume is enormous. The peaks are higher and the troughs lower. The result of this variability is a very uneven distribution of the need for nursing resources on any given unit. Patient classification systems are needed to accurately adjust staffing on a day-to-day basis, 26 which results in increased floating or voluntary/mandatory time off. At times whole nursing units open, close, and/or combine with other units. Nurses are required to cope with this kind of constant change, insecurity, and stress. In order to decrease the stress, many nurses who were specialized in one area of nursing cross-trained to gain some skill in a secondary area. This has provided more flexibility and job security for some staff nurses. Summary Since 1983 the health care system in the United States has undergone a radical change. A new system to fund the health-related costs for people covered by Medicare was instituted in order to preserve the trust fund that supports the Medicare program. This new system reimbursed hospitals for the care they provided according to a formula developed from the patient’s diagnosis (DRG). The purpose for instituting this new system was to contain, control, and finally decrease health care costs. Several factors in recent years have contributed to the changes nurses in the acute care setting have experienced. DRGs have provided a major focus for the attention around the changes, although other sociopolitical and economic realities have also had an impact. The reality of the DRG system has not been as good or as bad as predicted. Reimbursement by DRG has brought about alternations in length of stay and patient acuity as well as a shift in the delivery of care from inpatient to outpatient settings. Economic constraints have resulted in a 27 reallocation of staff and support roles. Perhaps the most significant changehas been a new consciousness and accountability about the cost- quality equation. All of the changes that have happened as a result of DRGs have had an impact on nursing. Educators, researchers, administrators and staff have all had a part to play in the response of the nursing profession to this change. The focus of this paper has been primarily on the changes as they have affected the staff nurse. Alterations in staff to patient ratio have been necessary, as well as patient assignments with high acuity being the norm. Budgets and accountability for them have become the responsibility of all nurses, both in staff and management positions. Cost management and quality care, previously seen as opposites, are being brought together by necessity. Ethical decisions about the allocation of resources are part of the daily practice of nursing in the ’805. As other control measures supplant the DRG system, new challenges will arise for nurses and nursing. The Chinese character for ”change" contains the elements of both ”danger" and "opportunity.” The crisis in Medicare funding has created a "significant opportunity” for nursing that is fraught with inherent dangers. To decrease the danger, nurses in all settings must work collaboratively to determine the direction of nursing practice for the next decade. 28 References Aiken, L.H., & Mullinix, CF. (1987). The nurse shortage: Myth or reality? New England Journal of Medicine, 317(10), 641-646. Beckham, S. (1983). Volunteer services: A way to ease the DRG crunch. Perioperative Nursing Quarterly, 1(3), 29-38. Champlin, L. (1985). DRGs: Putting the squeeze on your older patients. Geriatrics, 40(7), 77-81. Creighton, H. (1985). Legal implications of the DRGs. Nursing Management, 16(7), 17-19. ' Curtin, L. (1983). Determining costs of nursing services per DRG. Nursing Management, 14(4), 16- 20. Curtin, L L. (1984). Prospective payment: Winners and losers. In C. A. Williams (Ed.) Nursing research and policy formation. The case of prospective payment, (p. 69-73). Kansas City, Missouri: American Academy of Nursing. Davis, C.K. (1983a). The federal role in changing health care financing. Part I: National programs and health financing problems. Nursing Economics, 1(1), 10-17. Davis, C.K. (1983b). The federal role in changing health care financing. Part 11: Prospective payment and its impact on nursing. Nursing Economics, 1(2), 98-105. Davis, CK. (1984). The status of reimbursement policy and future projections. In C.A. Williams (Ed.), Nursing research and policy formation: The case of prospective payment (pp. 17-23). Kansas City, Missouri: American Academy of Nursing. Department of Health and Human Services (1983, September 1). Rules and regulations. Federal Register, 48(171), 39752-39890. Fetter, R.B., Shin, Y., Freeman, .l.L., Averill, R.F., Thompson, JD. (1980). Case mix definition by Diagnosis-Related Groups. Medical Care, 18(2) supp1., 1-53. Fosbinder, D. (1986). Nursing Costs/DRG: A patient classification system and comparative study. IONA, 16(11), 18-23. Grimaldi, PL. (1982). DRGs & nursing administration. Nursing Management, 13(1), 30- 34. Grimaldi, PL (1984). Regulations proposed for second PPS year. Nursing Management, 15(9), 60- 62. Halloran, EH1 & Kiley, M. (1984). Case mix management. Nursing Management, 15(2), 39- 45. Hamilton, JM (1984). Nursing and DRGs: Proactive responses to prospective reimbursement. Nursing & Health Care, 5(3), 155-159. Joel, L..A (.1983) DRGs: The state of the art of reimbursement for nursing services. Nursing & Health Care, 4(6), 560- 563. Joel, L. A. (1984). DRGs and RIMS: Implications. Nursing Outlook, 32(1), 42- 49. 29 Joel, LA. (1987). Reshaping nursing practice. American Journal of Nursing, 87(6), 793-795. " Kearns, J.M. (1987). The 1987 evaluation and update of the staffing criteria for the criteria-based model. Rockville, Maryland: US. Department of Health and Human Services. Kramer, M. & Schmalenberg, C. (19873). Magnet hospitals talk about the impact of DRGs on nursing care -- Part I. Nursing Management, 18(9). 38-42. _, . Kramer, M. & Schmalenberg, C. (1987b). Magnet hospitals talk about the impact of DRGs on nursing care -- Part 11. Nursing Management, 18(10). 33-40. Lewis, S. (1984). Prospective pricing and DRGs. Western Journal of Medicine, 140(1), 123-128. Levin-Epstein, M. & Sala, S. (Eds). (1985, August 21). DRGs: Impact on employee relations in the health care industry. White Collar Report, 58(8) Supplement, 3-31. Lichtig, L.K. (1982). Data systems for case mix. Topics in Health Care Financing, 8(4), 13-19. Maraldo, P. (1983). The world according to DRGs. National League for Nursing Public Policy Bulletin, 2(2), 1-4. McCormick, B. (1986, November 5). What’s the cost of nursing care? Hospitals, 60(21), 48-52. McKibbin, R.C., Brimmer, P.F., Galliher, J.M., Hartley, 5., & Clinton, I. (1985). Nursing costs & DRG payments. American Journal of Nursing, 8502), 1353-1356. Micheletti, J. & Toth, R. (1981). Diagnosis-related groups: Impact and implications. Nursing Management, 12(9), 33-39. Miller, N. (1987). The nursing shortage: Facts, figures, and feelings. Chicago: American Hospital Association. Mowry, MLM. & Korpman, R.A. (1985). Do DRG reimbursement rates reflect nursing costs? Journal of Nursing Administration, 15(7, 8), 29-35. , Newman, M. & Autio, S. (1986). Nursing in a prOSpective payment system health care environment. Minneapolis, Minnesota: University of Minnesota School of Nursing. O’Connor, P. (1984). Health care financing policy: Impact on nursing. Nursing Administration Quarterly, 6(4), 10-20. O’Lcary, J. (1985). With DRGs, blow your own horn. RN, 48(4), 87- 88. Piper, L.R. (1985). 10 ways to win the DRG game. RN, 48(3), 18-20. Reschak, G.L.C., Biordi, D., Holm, K., & Santucci, N. (1985). Accounting for nursing costs by DRG. JONA, 15(9), 15-20. RN, What you can do to cut costs under DRGs. (1986). 49(2), 52-56. Rutkowski, B. (1985). How D.R.G.s are changing your charting. Nursing, 15(10), 49-51. 30 Schniedman, R.B., Griffiths, E.,& Beblock, S. (1986). Streamlining care: . Meeting patient needs through DRGs. Nursing Success Today, 3(5), 23-28. Schwartz, W.B. (1981). The regulation strategy for controlling hospital costs: Problems and prospects. The New England Journal of Medicine, 305(21), 1249-1255. Securing the future. (1986). American Journal of Nursing, 86(7), 832-836. Shaf er, P.1..., Frauenthal, B.J., & Tower, C. (1987). Measuring nursing costs with patient acuity data. Topics in Health Care Financing, 13(4), 20- 31. Shaffer, F.A. (1983). DRGs: History and overview. Nursing & Health ‘ Care, 4(9), 388-396. . Shaffer, F.A. (1984a). A nursing perspective of the DRG world, Part 1. Nursing & Health Care, 5(1), 48-51. Shaffer, F.A. (1984b). Nursing: Gearing up for DRGs, Part 11: Management strategies. Nursing & Health Care, 5(2), 93-99. Shaffer, F.A. (ed.). (1985). Costing our nursing: Pricing our product. New York: National League for Nursing. Smith, CE. (1985). DRGs: Making them work for you. Nursing, 15(5), 34- 41. Spitzer, RB. (1983). Legislation & new regulations. Nursing Management, 14(2), 13-21. Staff Report (1985, September 26). Impact of Medicare’s prospective payment system on the quality of care received by Medicare beneficiaries». Washington, DC: Special Committee on Aging, United States Senate. Toth, RM. (1984). DRGs: Imperative strategies for nursing service administration. Nursing & Health Care, 5(4), 197-203. Veatch, RM. (1986). DRGs and the ethical reallocation of resources. Hastings Center Report, 15(3), 19-29. Weiss, B., Sheridan, D., Sommers, L., Kirkwood, B., & Silverman, J. (1987). Decreasing length of stay of hip replacement patients through effective discharge planning. Stanford Nurse, 9(1), 2-4. Woldum, K. (1987). Critical paths: Marking the course. Definition, 2(3), 1-4. Young, D.A. (1984). Prospective Payment Assessment Commission: Mandate, structure, and relationships. Nursing Economics, 2(5), 309-311. 31 NURSING CARE REQUIREMENTS IN LONG-TERM CARE .. REVISITED Sr. Lucia Gamroth, MS, MPA Acting Director Benedictine Institute for Long Term Care Review of the Literature Soon after the implementation of the prospective payment system (PPS), in which Medicare reimbursement to hospitals is based on diagnosis- related groups (DRGs), anecdotal material began to appear describing the "sicker patients" that long-term care (LTC) facilities were receiving. Lawlor (1984), in a nationwide poll of administrators and directors of nursing on long-term care facilities, reported "an increase in heavier care patients” in nursing homes (p. 4]), and a General Accounting Office (GAO) report (GAO, 1985) verified that providers across the country were concerned that earlier discharge of patients from hospitals was increasing care needs in long-term care settings. The GAO report noted that “the ' issues . . . are sufficiently important to warrant HHS [Department of Health and Human Services] studies . . . to analyze changes in long term care . . ." (p. 8). Several authors have pointed to what Wennberg, McPherson and Caper (1984) referred to as an "incentive inherent in the DRG system for hospitals to reduce the length of stay as a way of cutting costs” (p. 299). Grimaldi (1985) said that ”a system that pays a prospectively-determined amount per discharge encourages hospitals to avoid unnecessary days of 32 care and excessive ancillary services” (p. 8). The GAO report (GAO, 1985) confirmed that ”data on the use of hospitals under Medicare appear to show that hospitals have in fact responded by reducing lengths of stay” (p. 4). Thus, the literature leaves little question that there is an incentive in the PPS to discharge as early as possible. According to the GAO report (GAO, 1985), "while reducing the length of hospital stay may not affect a patient’s need for follow-up care, it is possible that some patients may be discharged at.a time in their illness when they have substantial needs for care" (p. 4). Wilder (1984) noted that "Patients are being discharged sooner and with an increased acuity level to nursing homes that must provide a significant amount of nursing care, medical supplies, and ancillary services" (p. 6). Barron and Schaeffer (1986) compared nursing care requirements on 25 patients admitted to an LTC facility pre-DRG with 25 post-DRG patients and found an increase in the amount and skill of nursing care requirements. Although this study provides a beginning point for description and quantification of nursing care requirements, it used a limited sample and did not control for case mix. Coe, Wilkinson, and Patterson (1986) compared dependency status at hospital discharge pre- and post-DRG for designated DRG categories and reported a significant increase in dependency for selected DRGs (pneumonia, heart failure, hip replacement). This study, however, included all hospital discharges within select DRGs and was not LTC specific; further, it provided an overall dependency score but did not describe dependency needs that represent 33 differences in nursing care requirements. In 1986, a study was completed that was a first step toward determining the effects of PPS on resource requirements in LTC. It was designed to (a) compare patients entering skilled facilities under the cost- based reimbursement system (CBS) and those entering under the prospective payment system so as to clarify the concept of "patients being ’sicker now,” and (b) explore the relationship between "sicker patients," length of stay in both the hospital and LTC facilities, and nursing care requirements in LTC. Method Records of 120 subjects admitted to LTC after hospitalization under a cost-based reimbursement system and no subjects admitted to LTC after hospitalization under the prospective payment system were reviewed to examine hospital length of stay, LTC nursing care requirements, and LTC length of stay. It was hypothesized that: (1) hospital length of stay for Medicare patients admitted to LTC facilities with these three diagnoses (hip fractures, CVAs, and "all other”) would be significantly shorter under PPS than'under CBS, (2) LTC nursing care requirements for Medicare patients admitted to LTC facilities with these diagnoses would be significantly greater under PPS than under CBS, and (3) LTC length of stay for Medicare patients admitted to LTC facilities with these diagnoses would be significantly longer under PPS than under CBS. This study was best represented as a separate-sample pretest-posttest 34 J design (Campbell & Stanley, 1963, p. 53). Data were collected across four time periods to test for significant differences within and between the pre-DRG and post-DRG periods. Two settings were selected, one rural and one urban, which were similar in size and Medicare program capabilities. Both facilities received referrals from several hospitals in two standard metropolitan statistical areas. The sample in each facility consisted of 120 Medicare patient records. Resource requirements were measured using the Patient Profile Instrument (PPI), which was derived from the Patient Review Instrument and the Patient Assessment Instrument, developed by the New York State Department of Health and Rensselaer Polytechnic Institute to provide a database for a patient classification system for LTC. The PPI consisted of two parts: administrative information, and medical condition. Administrative information included facility code, patient number, date of data collection, dates of last hospital admission and discharge, dates of last LTC admission and discharge, date of birth, sex, primary payor, discharge status, and disposition. Medical condition contained information on medical diagnoses as well as items measuring each of five aspects of nursing care requirements: medications, specialized services, psychosocial problems, unstable medical condition, and nursing treatments. Separate scores were obtained for each of the five subscales of nursing care requirements, with the scores representing the total number 35 of conditions present in each scale (each item was given equal weight in scoring). Higher numerical scores on the total nursing care requirement component indicated a "sicker” patient and lower scores, a healthier patient. Two tests of statistical significance were applied to the total sample data for each hypothesis. A one-way analysis of variance (ANOVA) was applied to test for between- and within-group differences represented by an F ratio and probability. Then t-tests were used to test for differences across subsets of samples. Results The length of hospital stay for patients under PPS was significantly shorter than under CBS. However, there was no significant difference in LTC length of stay under PPS and CBS. (Sec forthcoming issue of Image for details of the study.) There was a significant increase in the total nursing care require- ments under PPS. The two medication subscales and the nursing treatment subscale showed a significant increase in the number of interventions post- DRG. The nursing treatment subscale findings correlated highly with the total score on nursing care requirements and appeared to be the best indicator of nursing care requirements. A separate analysis of IV, IM and chemo medication did not show any significant increase. The subscales relating to special services, psychosocial problems, and medical instability did not show significant changes. 36 Subsequent Study The 1986 study was updated in 1987 with data collected on a sample of 60 records from the same two facilities for five time periods from October l, 1986 (time 1), to March 30, 1987 (time 5). A one-way analysis of variance was applied to the data to test for significant differences across the samples, and a t-test was used to compare pre-DRG and post- DRG changes. The level of significance used was 0.05. The charts represent graphically the changes across the five time periods for each variable or subscale. With the exception of the psychosocial subscale and the long-term care length of stay, all the subscales and variables showed significant (p < 0.05) changes in the hypothesized direction post-DRG (see Table 1). Several charts are of particular interest to the author. Although there seemed to be an initial drop in hospital length of stay, it begins to increase again, reflecting the acuity of those in the hospital. As the average number of medications by mouth decreases, the other medications, and particularly the IV, IM and chemo medications, increase. These changes correlate with significant increases on the instability and nursing treatment scales, which in turn correlate with the total scores. In the original study, 3 of 7 nursing care subscales showed significant change. In the follow-up study, 6 of the 7 showed significant change. The differences may represent a time delay of the effects of DRGs. It may also represent sampling error. However, replication of this study by 37 Table l. t-values and Probabilities for Nursing Requirement Subscales and Variables VARIABLE t-value probability MEDPO 2.33 ‘ 0.01 MEDS . 3.40 0.00 MEDSZ 2.26 0.01 SPSERV 1.94 0.03 PSYSOC -l.26 0.10 STABL 2.07 0.02 NURRX 5.31 0.00 TOTAL 3.83 0.00 LOSLTC 0.07 0.48 LOSHOS -3.62 0.00 Note: Values to the nearest hundredth. df=t(295). Planned comparison a t (comparison of times 1 and 2 with times 3, 4, and 5). another researcher supported the findings of the second study as did the anecdotes of the nurses working in LTC. One issue that these studies do not address is that of case mix. The sample included three diagnosis categories most frequently admitted to two Medicare LTC facilities. Equal numbers in each category were selected in an attempt to measure the differences within similar groups of patients. That is not to say that a facility has an equal mix of those patients at any one time. It is conceivable that a facility, at any given time, has a mix of those categories or a preponderance of one category, which may considerably change the nursing care requirements. That is an important consideration in interpreting the findings in both of these studies. 38 , I n | I ' I l 6 | n 1.: - I D | E A p 5 : a 1.0 /‘ I o s l H I l h I '5 I I I l e 3 a 5 l a 3 . I. "It nu: corIPMIsou or news On Minimums av mum conumsou or nzms ou omen nsmcanous 3.0 I s I 0.7 I P 2.: I n | s I ‘ °'5 I E 2.0 I D | R M s 0.3 | V L: I a I I 0.: 1.0 | I I a 3 a s I e 3 h 7 H: ‘ rm: cwmxsou or minus on Iv "1 no nemcnnous ‘ ‘ 9“ connmsou o: HEANS o~ spscm SERVICES I- 2.0 l 5 I v 1.5 | s I o I.o ' I c I 0.: I l I a 3 h 5 Im: CWARISDN OF NEWS ON PSYCHOSOCIAL 39 u-I,-C. I P r9-oo-u 1-5 I G I no - I I I I ' l I a a a 5 I 2 3 6 nu: 1an CWMISON 0' "EMS 0" WITH-I CONN?!” cwMIsou 0: means on nuasmo mun-Imus I “° l I I I I. as I I , I I I 3° I I I '5 I I I I ' ' I0 I I I I a. I ' ’ ’ I I 3 a 1m: nu: cmPMIsou or news on tom. scones conmmson o: nuns on LTC Lemma 0: smv n as I o l I go I r o I I: t I II II: I L I 5 l I I I a 3 '- 5 1m: Z’II VI W2C: N I! 1 A manna" W mm ON ”WITN- LENBT“ OF IN“ 40 Conclusions The major findings from these studies were that the overall hospital length of stay decreased while the overall nursing care requirements increased under PPS as compared to CBS, and that LTC length of stay remained the same for patients admitted to Medicare skilled nursing facilities. The findings have implications for nurses in LTC facilities, who are experiencing high stress and are looking for other employment opportuni- ties. Nurses who have chosen a specialty practice in gerontology and chronic disabilities are finding that they must practice as acute care providers for the nursing care patients now being admitted to LTC. LTC facilities have added more RN and RN-specialty. hours in an attempt to meet these increased needs. As administrators, LTC nurses must be concerned with the patient requirements for more nursing care in the face of rigid reimbursement structures that do not allow for increased staffing. The role of the Director of Nursing Services has changed, requiring a broader view of the long-term care system and its environment. These changes have important implications for education. Nurses are asking for whole new knowledge areas such as ethics, and reimbursement. They are needing more knowledge in specific areas, for example, tech- nology or the latest on wound care. Licensed practical nurses are feeling the need for more education and are returning to school for RN training. 41 References Campbell, D.T., & Stanley, J.C. (1963). Experimental and quasi- experimental designs for research. Boston: Houghton Mif f lin. Coe, M., Wilkinson, A., & Patterson, P. (1986). Final report on the dependency at discharge study (HCFA Grant #lS-C-98862/0-0l). Beaverton, OR: Northwest Oregon Health Systems. General Accounting Office (GAO) (1985). Information requirements for evaluating the impacts of medicare prospective payment on post- hospital long-term-care services: Preliminary report. (GAO/PEMD- 85-8). Washington, D.C.: US. General Accounting Office. Grimaldi, P. (1985). DRGs and long-term care. American Health Care Association Journal, 11(1), 6, 8- 9. Barton, J. & Schaeffer, J. (1986). DRGs and the intensity of skilled nursing. Geriatric Nursing, 31- 33. Lawlor, A. (1984, November). Reader roundup: Sickcr patients trigger staff alternations. Today’s Nursing Home, 5(1 1), pp. 1, 41-42. Wennberg, J.E., McPherson, K., and Caper, P. (1984). Will payment based on diagnosis-related groups control hospital costs? The New England Journal of Medicine, 311(5), 295-300. Wilder, RS, (1984, October 25). The effects of hospital DRGs on nursing homes. Long Term Care Management, 13(24), p. 6. 42 THE IMPACT OF HOSPITAL DRGs ON NURSING CARE IN COMMUNITY HEALTH SETTINGS Dorothy Kleffel, RN, MPI-I Director of Education and Research The Visiting Nurse Foundation, Inc. The change from a cost reimbursement system to a prospective pay system (PPS) for hospitals in 1983 created a financial incentive to discharge patients as quickly as possible. Patients were referred to community health services in order to receive continued care outside the hospital. Community health nurses felt the ripple-down effect from the hospital prospective pay system shortly after implementation, and it is still continuing. This paper addresses the impact of the Diagnostic Related Groups (DRGs) prospective pay system upon one type of community health agency, the home health agency. Background The first organized programvof home health care was the Boston Dispensary, developed in 1796. At that time only the poor went to the hospital, while the wealthy were treated by physicians in their own homes. The Boston Dispensary program's philosophy was to bring care to the sick at home thus avOid the stigma of the charity hospital. Precursors to the present Visiting Nurse Associations were founded as voluntary agencies in Buffalo, New York City, Boston, and Philadelphia in the 18005 and expanded throughout the country. 43 In some geographical areas, especially the west and the south, voluntary agencies were slow to develop and official health departments assumed responsibility for home health care. Nursing was the only service provided by these early programs until the 19405 when hospitals began developing hospital-based home health agencies, which provided a broader scope of services (Ryder, 1969). The Medicare and Medicaid legislation of 1965 required specific conditions of participation for home care agencies to be eligible for reimbursement. The intent of- the law was to encourage the provision of comprehensive services by requiring home health agencies to provide at least one other service in addition to nursing. One effect of the Medicare legislation was to change the focus of home health services from a long-term social and medical program to a short-term acute care medical model delivery system as agencies shaped their programs to meed Medicare coverage criteria. Today, home health agencies are administered in the traditional settings of visiting nurse organizations, health departments, and hospitals as well as skilled nursing facilities, rehabilitation hospitals, and health maintenance organizations (HMOs). A fairly new event is the development of the free-standing proprietary home health agency. There are just under 6000 Medicare certified home health agencies nationwide. They vary widely in size, geographical area covered, scope of services, types of health personnel, and organizational structure. The implementation of the hospital DRG system, along with other trends in the health field, has impacted home health agencies dramatically. The purposes of this paper are to describe the forces influencing home 44 health agencies, discuss their effect on quality of care, describe the survival strategies of one home health agency, suggest needed research, and predict the future of the field of home health. Forces Shaping the Nature of Home Health Several forces impinged almost simultaneously upon the field of home health around 1983, changing the face of home health nursing forever and making it difficult to evaluate the impact of .the hospital DRG prospective pay system as a separate occurrence. These forces include (1) an increase in the number of patients referred to home health care, (2) the advances of high technology, (3) admission of a greater number of acutely ill patients, (4) a federal policy of restricting the Medicare home health benefit, (5) federally mandated uniform data collection, and (6) increased competition among home health agencies. Increased Number of Patients One positive result of the hospital DRG system has been the changed perception of home health as part of the mainstream of the health care system as hospitals are looking for alternatives to inpatient care. In the search for alternatives, home health became highly visible. Home health agencies are reporting an increased number of patients admitted to service, especially those 75 years old and older (Wood, 1984). Discharges to home health care rose 37 percent between October 1983 and March 1985 (Staff 45 Report, 1985). Effects of an increased volume of patients are adding and retaining personnel, programs, and services. The current shortage of skilled personnel, especially nurses, is creating competition among home health agencies, hospitals, and other health agencies for scarce personnel. Although home health agencies are benefiting from disillusioned hospital nurses seeking a different area for practice, there are still not enough nurses. New programs and services are being developed by home health agencies in order to better serve the added volume of patients. Hospice, respite, psychiatric, durable medical equipment, and attendant care are examples. Technological Advances Recent advances in medical technology have made it possible to care for certain categories of patients safely at home that a few years ago could be cared for only in the hospital. Administration of intravenous infusions, antibiotic therapy, and enteral therapy via Hickman and Broviac catheters; use of insulin pumps; laboratory and other diagnostic and therapeutic procedures have been performed by home health nurses since the early l980s. But the demand for these services has greatly accelerated since the advent of the hospital DRG prospective pay system as hospitals are attempting to shorten lengths of stay (Auerbach, 1985). Caring for ventilator-dependent patients at home is becoming more frequent. Nurses in some home health agencies are “successfully administering blood transfusions at home (Marek & McVan, 1987), and the demand for this type of therapy is increasing rapidly. The need for nurses with'high-tech skills is accelerating rapidly, resulting in recruitment competition already mentioned. Sicker Patients Related to advances of high technology and earlier discharge of patients from hospitals is the increasing acuity of patients being admitted to home care (Taylor, 1985). Patients require more complex nursing care on a 24-hour basis by highly skilled nurses. This, in turn, lowers nurse productivity because of the greater use of nursing resources in both giving and documenting care. Lowered productivity increases costs to the agency. Increased acuity of illness in patients, along with reluctance on the part of Medicare to pay for the care that they require, has resulted in concern by nurses regarding the adequacy of services and the fear that the needs of the less acutely ill patient will not be met. Restrictive Federal Policies Access to home health care benefits is being restricted by the Health Care Financing Administration (HCFA) through its Medicare intermediaries by a stringent review of each home health Medicare claim and the imposition of Medicare cost caps. Medicare denials. Intermediary decisions regarding homebound status, 47 medical necessity, and intermittent and skilled care are made rigidly and without allowances. Interpretation of homebound status has become so strict as to almost mean bedbound, as the Medicare coverage regulation that allowed the patient to be absent from the home for short periods of time if it does not indicate that the patient had the capacity to obtain care outside of the home is ignored. ‘Sicker‘ patients often require more than 21 days of daily intermittent nursing care allowed by Medicare, and many of the billing claims for patients requiring additional daily care have been denied payment. On the other hand, some payments are denied because the care requirements are too complex and require more than intermittent home care. The patient's need for skilled nursing has to be documented extensively and home care nurses must justify that a nonmedical person is not willing or not able to safely deliver care in order for a claim to be paid. Intermediary decisions across the nation are inconsistent, and it is increasingly difficult for nurses to anticipate what care will be reimbursed. Denial rates jumped from 1.2 percent nationally in 1983 to 8.1 percent in June of 1987 (Home Health Line, 1987). The American Federation of Home Health Agencies (AFHHA) analyzed data on denials of home health visits that were paid under waiver1 and found that about 70 percent of patients 1 Medicare will waiver the liability and make payment if the intermediary determines that the home health agency staff did not know, and could not reasonably have been expected to know, that the services were not covered. If more than 2.5 percent visits are denied, the agency will lose its favorable waiver status. 48 whose care was denied were subsequently institutionalized and/or died. Half of these patients were over 80 years old and. virtually all of them had multiple diagnoses (Home Health Line, 1985). Intense review by intermediaries resulted in a substantial number of home health agencies losing their favorable waiver status. When an agency is off waiver, it may request the intermediary to reconsider the denied visit(s). However, intermediaries are backlogged several months and the lost revenue for this period of time causes severe cash flow problems for the agency. The situation became so critical that in 1986 the American Nurses Association (ANA) House of Delegates adopted a resolution at their June business session calling upon the ANA to work aggressively to stop the dismantling of the Medicare home health benefit. The home health industry itself has lobbied Congress intensively and the denial situation presently seems to be slightly easing (National Association for Home Care, 1986). Cost caps. Prior to 1985, home health agencies were reimbursed by the Medicare prOgram for their reasonable costs, not to exceed the 75th percentile of aggregate agency costs. Under this system, if an agency exceeded costs in one discipline but was under costs in another discipline, the costs could average out and the agency not lose money. Under the new rule, home health agencies are reimbursed at 120 percent of the mean of visit costs and are not permitted to aggregate these costs. The regulation called for an automatic reduction to 115 and 112 percent of the mean of visit costs in the two subsequent years. The effect of this 49 regulation was to cause agencies to lose money on any discipline’s visits that exceeded the caps, even though it was under caps in another discipline. This regulation was rescinded in March of 1987, but most agencies lost a great deal of money in the time that it was in effect. There is still controversy on how the cost caps are calculated because HCFA is using data from 1983 and adding an inflation factor that does not reflect administrative costs caused by change in mandated data collection Uniform Data Collection HCFA instituted a uniform plan for home health patient data collection, which was implemented in 1985. Although home health agencies supported the concept of uniform data collection, the information required for each patient is incredibly detailed and requires an inordinant amount of time to complete the forms. It also requires increased supervisory review for accuracy and completeness before submission to the intermediary. This is necessary because nurses must attempt to justify delivery of patient care for reimbursement purposes. The more time that a nurse spends on paperwork, the less time she or he is spending giving patient care. This, in turn, lowers productivity with resulting decreased reimbursement to the agency. Increased Competition Home health competition began with an increase in the number of proprietary home health agencies entering the field in 1981, as a result of 50 a change in federal regulations that allowed proprietary agencies to become Medicare certified in states that had no licensing law. The hospital DRG system implemented two years later was an incentive for many hospitals to start their own home health agencies in an effort to shift expenses from a prospective pay system to the cost reimbursed system now employed by home health agencies. The number of hospital- based home health agencies has increased at a far greater rate than any other type of home health agency. From December 1984 to March 1986, 394 hospital-based agencies began operations (Home Health Line, 19863). The total number of home health agencies nationwide increased from 3,639 in December 1983, reaching a peak of 6,012 in April 1986 (Home Health Line, 1986b), and decreasing slightly to 5,877 in 1987 (National Association for Home Health Care, 1987). In summary, financial incentives imposed upon the hospital in the form of the hospital DRG prospective pay system encouraged the use of home health benefits at the same time that federal policies greatly restricted the use of home health, causing a gap between patients’ needs and the care reimbursed by Medicare. Impact on Quality of Care Quality of care is a concern of home health nurses as staff are asked to take care of sicker patients needing complex care while maintaining the same productivity standards as before hospital DRG implementation. Restrictive interpretation of Medicare coverage and lack of a national 51 home health policy with appropriate and adequate funding impacts the delivery of comprehensive care at home (Ramage, 1985). Quality Assurance Activities The major quality assurance activities that were traditionally performed by home health agencies prior to the passage of Medicare were supervised home visits and supervisor-staff nurse case conferences. When Medicare regulations were written, requirements for policy and administrative review and clinical record review were mandated. As part of clinical record review, there is a requirement for continuing review of records for each 60-day period that apatient receives home health services to determine adequacy of the plan of treatment and appropriateness of continuation of care. There are no Medicare utilization review'requirements, although many states, such as California, do require utilization review to be performed as part of the state licensing law. Quality assurance studies are not presently required, although hospitals that contract with a home health agency may require them. Therefore, at present, the major quality assurance activities of home health agencies are the supervised home visit, case conferences, policy and administrative review, and clinical record review, which includes 60-day continuous record review. Home health agencies must also comply with Medicare certification and state licensing requirements. There are three organizations that accredit home health agencies. Accreditation is available for hospice and 52 home health agencies by the Joint Commission on Accreditation of Hospitals; the National League for Nursing has an accreditation program for home care and community health; and the National HomeCaring Council, a division of the Foundation for Hospice and Homecare, has an accreditation program. Quality of Care Problems Quality of care problems reported by home health agencies after hospital DRG implementation include inadequate communication between hospital discharge planners and home health agency personnel, resulting in lack of sufficient patient information for the home health nurse to plan care. In a survey conducted by Pesznecker, Horn, Werner, and Kenyon (l987), respondents reported patients and families arriving home and not knowing how to manage care, concern that home care was unsafe or inadequate to deal with the patient‘s condition, lack of a competent and willing caregiver, and proliferation of unsldlled and unsupervised health care personnel in home settings. Home Health Agency Survival Strategies Although high-tech home health nursing, admission of more acutely ill patients, and cbmpetition among home health agencies began pre-hospital DRG, the added burden of increased Medicare denials, Medicare cost caps, and the implementation of the hospital DRG system had a major impact upon home health patients, staff, agencies, and the industry. Home health ~53 agencies responded differently to the pressures and forces that have been described. This paper reports on the survival action taken by one agency, the Visiting Nursing Association of Los Angeles (VNA-LA). The VNA-LA is the largest home health agency in the west, encompassing about 4,000 square miles and operating out of six area offices. Services including nursing; physical, occupational and speech therapies; medical social work; home health aide services; and nutritional and pharmacological consultation. Last year the agency made over 200,000 visits. Of these, about 112,000 were nursing visits. About 70 percent of the visits are made to Medicare beneficiaries. Some of the immediate effects that VNA-LA nurses reported as the impact of the hospital DRG system hit the agency were: " patients were being discharged home more acutely ill and in precarious and unstable conditions, which sometimes resulted in rehospitalization; " patients had inadequate teaching and did not understand their illnesses or medical'regimes as hospitals, of necessity, curtailed their teaching activities; patients and families were overwhelmed and insecure about their abilities to give the required complex care and felt that ‘ patients had been discharged from the hospital too early. A survey conducted at the VNA-LA confirmed that VNA—LA nurses perceivedthat they were caring for sicker patients. Most felt that patients should be kept in the hospital longer. Interestingly, most nurses 54 also felt that patients could be managed at home (Luque & Frey, I987). Focused Educational Activities Never had the need for staff education been greater in VNA-LA than when at the same time cost containment policies limited the amount of money available for educational activities. Therefore, educational resources have had to be focused in those areas critical to Our survival. High technology skills. The VNA-LA took a two-pronged attack in attempting to rapidly increase its ability to provide high technology patient care. The first was to upgrade the skills of its existing staff, and the second was to employ hospital nurses who previously worked in critical care areas. Both groups of nurses had different educational needs. Existing staff needed courses in clinical areas such as intravenous therapy, intravenous chemotherapy, antibiotic therapy, total parenteral nutrition, use of Hickman and Boviac catheters, use of new equipment (glucose monitors, autosyringes, intravenous lines, pumps, ventilators), wound and ostomy care, medication updates, decubitus ulcer updates, diabetic management, care of the terminally ill, and in-depth physical assessment skills. Hospital nurses new to the field of home health needed to broaden their scope of interventions from patient and hospital centered care to family and community care. They needed orientation to the field of home health, skills in coordinating care using a multidisciplinary and multiagency team approach, family and environmental assessment skills, family 55 psychodynamics, and a knowledge of community resources. Documentation skills. The home health agency receives a major portion of its revenue based on nursing documentation; therefore, it is imperative that nursing documentation is relevant and complete. Documentation is extensive because the parameters of nursing practice cover a greater area than inéhospital nursing and the patients’ physicians do not write in the home health agency record. The record either validates or fails to validate care for legal and reimbursement purposes based upon the nurse’s or other home health discipline’s documentation. Nurses develop the Plan of Treatment based on physicians’ orders and nursing assessment of the patient and home situation. The plan is mailed to the physician for signature and is sent to the intermediary along with the billing claim, which become the data for review for reimbursement purposes. Areas of inservice on documentation needed by nurses include all aspects of Medicare home health coverage criteria; assessment of the patient, family, and environment; development of a Plan of Treatment; patient progress; and patient discharge summary. Management and specialty skills. The role of nurse managers becomes critical for efficient, effective operation of the agency as pressures upon the agency mount. Nurse managers need. education in areas of health organization and financing, budgets, health politics, computers, and marketing and research, as well as traditional supervisory and administrative skills and techniques for functioning in today's environment. Administering a home health agency has become a complex business, 56 and nurse supervisors’and managers need advanced education in order to function effectively. Also the need for nurse specialists (such as pediatric nurse practitioners, psychiatric nurse practitioners, hospice nurses, and enterostomal therapists) is increasing. The agency must assist its nurses in obtaining appropriate education in order to remain competitive, and the VNA-LA has provided financial assistance to nurses wishing to obtain advanced degrees in administration or in specialty areas. Service and Organizational Changes The forces converging upon the VNA-LA have resulted in a complete change in the way that its business is done. Specialization, hours and days of business, payment methods, and changes in the organization of the agency itself have been made. Specialization. Although the trend toward specialization in home health began pre-DRG, it was accelerated as home health nurses tried to meet the varying needs of their patients. The VNA-LA has added three nursing specialties since hospital DRGs were implemented and now has the following nursing programs: medical/surgical, infusion, pediatric, enterostomal therapy, respiratory, psychiatric, and hospice. Extended hours of service. Patients needing high-tech care or intensive and complex nursing care can need services at any hour, and the VNA-LA has extended its services to include making visits on weekends, holidays, evenings and nights, and to provide on-call services 24 hours each day. Evening and night visits present potential safety problems in 57 some geographic areas, and the agency provides escort services for nurses who make these visits. Gone are the days when home health nursing was an 8:00 to 5:00, Monday through Friday job. Reorganization. ‘By 1985, it became obvious to management and the Board of Directors of the VNA-LA that the effects of the forces that have been described were threatening the survival of the VNA-LA. The mission of the VNA-LA is to provide high-quality home health care based on need regardless of the patient's ability to pay. Although the agency is a United Way agency, the funds provided cannot subsidize Medicare beneficiaries, Me'diCal (California’s Medicaid Program) recipients, and indigent patients. Additional sources of funding had to be found. Under Medicare regulations marketing and fundraising activities are not allowable costs and, if performed as part of the home health agency, must carry a share of Medicare’s overhead administrative costs. Therefore, in order to raise money to care for needy patients, the agency reorganized into three organizations: The Visiting Nurse Foundation is the parent organization that administers the three agencies, raises funds and markets for new referral sources. The Visiting Nurse Home Services provides shift nursing and attendant care to patients who can pay. The Visiting Nurse Association of Los Angeles, Inc. is a Medicare-certified, state-licensed intermittent home health agency. Revenue over costs from the Foundation and the Home Services, which are nonprofit organizations, are channeled into the VNA-LA to subsidize care for indigent patients. In 1985, the Foundation entered into a joint venture and acquired The Visiting Nurse 58 Home Pharmacy. This is a profit organization, and its profits are also channeled into the VNA-LA. Most staff nurses remained with the VNA-LA and were not greatly affected by the reorganization. However, the reorganizatiOn did give opportunities to nurses to transfer among the organizations as new positions opened up. Marketing and public relations. Extensive marketing and public relations were not perceived as necessary prior to the competitive atmosphere of the last few years. Now, however, the marketing of services to hospitals, health maintenance organizations, insurance companies, and the public is necessary in order to increase referrals and maintain visibility. Marketing and public relations activities are performed by the Visiting Nurse Foundation for all of the corporations, and nurses have the opportunity to extend their skills into these areas. Fundraising. Related to marketing and public relations is the ability to raise money in order to create a stable financial base for the agency and to help subsidize care for needy patients. A director of development was employed full time in 1985, and for the first time the agency has the capacity to create a large giving support group, create an auxiliary, V conduct direct mail solicitation, manage special events for fundraising purposes, research foundation guidelines for possible funding, and write grants. Nurses have input into the annual funding needs assessment and have 59 received professional benefits from f undraising activities. Video equipment has been obtained and provided to each area Office for educational _ purposes. Educational videotapes are being produced, and some nurses are involved in the production of the tapes. The fundraising priority for next year is to raise money for automation of the agency’s patient care record system. Pay for Visit program. A new method of paying nurses had to be designed as nursing productivity, which is counted by number of visits in home health, decreased as a result of caringfor patients needing more care and the added burden of increased documentation requirements. Medicare reimburses the same amount of money whether the visit takes 15 minutes or four hours. As productivity dropped, the agency received less money for the same number of nursing hours, which helped to cause a severe financial crisis to the VNA—LA. To respond to this crisis, the VNA-LA implemented a Pay for Visit incentive program for nurses and other disciplines in June 1987. This program is designed to reimburse nurses according to the number and complexity of visits. Admission and specialty visits are given added weight. If a nurse makes the productivity standard, she or he is reimbursed at base pay. If the standard is exceeded, the nurse receives more than base pay. If the standard is not reached, the nurse receives less than base pay. Orientation, inservice, and other non-visit activities of the nurse are paid at the base pay rate. The nurse must attend team conference meetings and otherwise meet the documentation and quality assurance standards of the agency. The nurse 60 is still an employee of the VNA-LA and receives full benefits. The system rewards organized and efficient work, and nurses have more autonomy in their practice as they are free to accept or not accept visits as long as patients receive needed care. The program is too new for complete evaluation but nurse acceptance of the Pay for Visit system has been good and nurse productivity has increased. The agency saved $13,000 on nursing alone the first month of implementation, and $25,000 the second month. The savings occur because of increased productivity and the use 'of VNA-LA staff rather than outside temporary or per diem nurses. Cost containment. Other cost containment measures that the agency reluctantly took were a reduction in personnel, a wage freeze, a decrease in the number of educational activities that were conducted or reimbursed, and the purchase of only essential items that were critical to the operation of the agency. Nurses and other staff cooperated with the cost containment strategies that management and the Board have taken, and the agency’s financial position is much improved at the present time. Research Needed Research in the field of home health has been almost nonexistent until the last few years, leaving home health managers and planners without solid information on which to base their activities. Fortunately the situation is improving as home care is moving into the mainstream of the health care system. Because nursing is the most utilized home health 61 service, the field is ripe for nursing research. The following are suggested areas of nursing research in the field of home health: * The clarification of the impact of the hospital prospective pay system from‘the other forces influencing home health is a major research need. “ The development of home health nursing care standards and criteria by which to measure quality is an area of great need, as there are none that are widely accepted. “ There is a resounding need for a classification tool that can measure the patient’s use of nursing resource utilization or patient acuity for setting productivity standards, scheduling, and projecting costs. Medicare reimburses the same amount of money per visit regardless of how long the visit lasts. Some way of measuring the use of nursing resources and fairly allocating costs needs to be devised. Several researchers have approached this issue, and the literature was reviewed by Churness, Kleffel, Jacobson, and Onodera (1986). The Visiting Nurse Foundation and the University of Southern California Department of Nursing are cooperating in the development of a classification system (Churness et al. 1986). Once a valid and reliable tool is developed it can also be used for other research such as the measurement of the complexity of nursing care needed by patients pre- and post-hospital DRG implementation. A national project titled "Develop and Demonstrate a Method for Classifying Home Health Patients to Predict Resource Requirements and to 62 Measure Outcomes” has recently been awarded to Georgetown University School of Nursing and funded by HCFA. Project products will include an assessment tool, a classification tool to predict resource requirements, a computer system to process the assessment, classification and outcome measurement data, and a database of home health agency and Medicare patient characteristics. Pertinent research suggested by other authors are to: “ Identify what product is being delivered by home health agencies, the extent to which the product meets the needs of patients, how agencies can improve their services and increase their range of services using quality of life and outcome measures (Rogatz, 1985). ‘ Assess whether the provision of home health care replaces the services provided by the family, friends, and neighbors at no cost (Rogatz, 1985). * Conduct nursing management studies in the areas of staff mix, delivery models, shortened lengths of stay, and outcomes (Feldman & Goldhaber, 1984). " Study characteristics of caregivers who are capable of learning and managing complicated high technology procedures in the home (Pesznecker et al., 1987). Home Care of the Future Home case is changing rapidly, and there is no doubt that it will continue to grow, but it will be a very different health delivery system in 63 the 20005 than it was in the early 19805. Many of the present agencies will not be here. Levels of Service Expanded Home care presently has at least three levels of care: acute short- term care, long-term care, and preventative care. Medicare reimbursement is available for short-term care, but there is almost no reimbursement for long-term or preventative care. The present hospital-driven, acute care medical model, which is the structural basis of the Medicare program, will be forced to give way as the population ages and the incidence of chronic diseases increases. If the basic premise is accepted that patients have a right to be treated in the least restrictive environment compatible with safety and expense, community-based services must be expanded. Home care services are appropriate, less expensive (Cabin, 1985), often preferred by the elderly (Cetron, 1985), and must be offered on a variety of levels in order to meet present needs as well as to plan for the future. The provision of home health services can prevent, minimize, or delay dependency, but existing reimbursement mechanisms will have to be changed in order to provide a broader range of services before its potential can be met. Cowart (1985) suggests that changing Medicare reimbursement to nursing diagnosis from medical diagnosis would allow home care to render maintenance and preventative services. This is a reasonable approach, as patient problems are often primarily nursing by the time patients are admitted to home care. 64 Technological Advances Technology will continue to advance and be made available in the home care setting. New home care services on the horizon include caring for organ transplant recipients and artificial organ patients; mobile and home surgeries; electronic body and body chemistry monitoring; robotic medication reminders, adjustment of IV medications, automated massage; and computer controlled environments (Shaw, 1985). Computerized medical records and/or video documentation are eagerly awaited by all home care nurses. Home Health Prospective Pay System Some sort of prospective pay system designed for home health agen- cies is a certainty; however, the form it will take is not yet clear. The home health industry generally supports the concept of PPS, hoping for at least predictability in reimbursement and a decrease in the amount of documentation and related administrative burden now required by Medicare. Home health associations have been developing PPS proposals hoping to have input into the system. Recently HCFA officials met with home health leaders and announced their intention to move to a PPS system for home care within two years (National Association for Home Care, 1987b). Greater Competition Competition among home health agencies will continue to increase significantly, resulting in continued diversification and corporate 65 reorganization of individual agencies. Managed care will become more common as individual agencies continue to link up with hospitals, health maintenance organizations, social health maintenance organizations, and preferred provider organizations, or they may merge or affiliate with other home care agencies to increase service capacity while reducing overhead and administrative costs (Reif, 1984). Some agencies will be acquired and others will yield to adversarial takeover. Many nonprofit agencies will start profit-making ventures in an effort to obtain enough capital to continue to exist. Marketing and advertising will increase in order to attract new referrals, and fundraising will become widespread. Home health will be in the ”big time" and will suffer the advantages and disadvantages of big business. Greater Regulation of Quality of Care Quality of care will become a bigger issue as the squeeze is put on home health agencies to produce more with less. Home health will be required to meet quality assurance standards and will come under the Professional Review Organization’s (PRO’s) purview in 1987 or l988, depending on when the individual PRO’s contract is renewed by HCFA. Tomorrow’s Home Health Nurse One of the greatest challenges of home health care nurses of the future will be to balance humanism with high-tech care. Presently the home is a good place to practice humanistic nursing, but this can be 66 threatened because of the pressures of increased productivity coupled with advances of high technology. Tomorrow‘s home health nurses will be better prepared than today’s nurses. They will have a good background in geriatrics in order to care for the cohort of baby boomers who will be old in twenty years. This new nurse will be autonomous and possess physical assessment skills equal to that of a primary nurse practitioner, but will also be able to assess the home environment and family interaction and dynamics. Teaching will continue to be a major component of home health nursing, and the new nurse will have very good teaching skills in order to teach patients, families, attendants, home health aides, and colleagues. Case management will be a growing role for the home health nurse who will be able to establish long-term relationships with patients and families, understand the role of the team members, be able to work with each collaboratively, and be very familiar with community resources in order to coordinate care. Familiarity with computers for documentation will be routine for this nurse. Understanding home health reimbursement issues, health organization and politics will be necessary to function effectively. He or she must be able to make efficient use of time and resources and be able to work in constantly changing large corporations or businesses and still maintain professional integrity. Flexibility and a sense of adventure will be an asset to fill new roles that will certainly emerge. 67 References Auerbach, M., (1985). Changes in Home Health Care Delivery, Nursing Outlook, 33, 290-291. Cabin, W., (1985). Some Evidence of the Cost-Effectiveness of Home Care, Caring, 4, 62-67, 70. Cetron, M, (1985). Public of Home Care: A Survey Report Summary Caring, 4, 12-15. Churness, V., Kleffel , D., Jacobson, J., & Onodera, M, (1986). Development of a Patient Classification System for Home Health Nursing. In F.A. Shaffer (ed.), Patients & Purse Strings: Patient Classification and Cost Management (pp. 319-330). New York, N.Y., National League for Nursing. Cowart, ME, (1985). Policy Issues: Financial Reimbursement for Home Care, Family and Community Health, 8(2‘)'9. Feldman, J., & Goldhaber, El. (1984, May). Living with DRGs, The Journal of Nursing Administration, 22. Home Health Line, American Federation of Home Health Agencies is Analyzing Data on Denials, (1985, June), p. 158. Home Health Line, Changing Face of Medicare Home Health, (1986a, March), p. 95. Home Health Line, Hospital-Based Providers Gain Among Certified HHA’s, (1986b, September), p. 302. Home Health Line, National Home Health Denial Rates, (1987, August), p. 302. Luque, Y., & Frey, D., (1987, October). Pharmacology Assistance Program: Cost-effectiveness and Evaluation. Paper presented at the annual meeting of the National Association for Home Care, Washington DC. Marek, K., & McVan, B. (1987). Home Transfusion Therapy: A New Dimension in Home Care, Quality Review Bulletin, January 17-20. National Association for Home Care, American Nurses Association Resolves to Stop Dismantling of Home Health Benefit. (1986, July), Report, p. 2. National Association for Home Health Care, Medicare-Certified Home Health Agencies Now Number 5,877. (1987a, August), Report, p. 5. National Association for Home Health Care, HCFA Springs Surprise: Moves Toward Prospective Payment for Home Health Agencies. (1987b, September). Report, p. 1-2. Pesznecker, B., Horn, 3., Werner, J., & Kenyon, V. (1987). Home Health Services in a Climate of Cost Containment, Home Health Services Quarterly, 8, 13-14, 19. Ramage, Nelle, B., (1985). ln-home Health Care Services: A Policy Perspective, Family and Community Health, 8, l7. Reif, L., (1984). Making Dollars and Sense of Home Health Policy, Nursing Economics, 2, 386. 68 Rogatz, P., (1985). Home Health Care: Some Social and Economic Considerations, Home Health Care Nurse, 3(1), 39, 41-42. Ryder, C.F., (1969). Home Health Services--Past, Present, Future, American Journal of Public Health, 59, l720-l724. Shaw, S. (1985). 200] . . . A Home Care Technology, Caring, 4(10), 20- 23. Staff Report, (1985). Impact of Medicare’s Prospective Payment System on the Quality of Care Received by Medicare Beneficiaries, Special Committee on Aging, United States Senate, Hohn Heintz, Chairman, October 24, 5. Taylor, MB., (1985). The Effects of DRGs on Home Health Care, Nursing ‘ Outlook, 33, 288-289. Wood, 1.3., (1984). Public Policy and Current Effect on Home Health Agencies, Home Health Care Services Quarterly, 5, 80. 69 IMPACT OF DRGs ON UNDERGRADUATE NURSING CURRICULUM Carol A. Lindeman Dean, School of Nursing The Oregon Health Sciences University In 1970, Carol Taylor (1970) described one of the most recent changes in hospital behavior: the big-business look. She stated: When hospitals think of themselves as part of an industry, they begin to adopt practices that have proved to be productive in industry. I call these innovations ”big-business behavior.” One of the interesting things about the hospital’s big-business behavior is that much of it is used in a somewhat magical manner. The hospital tends to take over practices that have proved useful to industry without modifying these practices to fit a somewhat different set of conditions. The hospital makes the same gesture that industry makes, and it seems to expect the same results. Taylor provided examples of costing-behavior in hospitals to support her observations that the cost figures being produced were not helpful in analyzing production costs. Using an example from cost-per-meal, she stated: This figure [cost-per-meal] was not accompanied by a statement about what had been included and excluded to arrive at the cost- figure, and there was no way of knowing whether or not the figures used in the original arithmetic were accurate cost-figures. 70 As hospitals assumed more and more of the big-business image, conflicting frames of reference arose over aspects of hospital care. One such conflict was the phenomena of admitting persons on the basis of their ability to pay their bill. She offered this scenario: The administrator is responsible, among other things, for keeping the hospital out of debt. He is delighted when patients’ can pay their hospital bills, and he is tempted to_ order "red carpet" treatment for those patients who might donate money to the hospital in addition to paying their bill. The physician has inherited the tradition of allowing the ”rich" patient to contribute to the care of the "poor" patient. Special consideration for the patients who are in a position to make substantial donations to the hospital, or for medical research, does not seem unreasonable to the physician. The nurse‘s reactions to the patient’s pay category are more complicated than the reactions of either the administrator or the physician. Like the administrator and the physician, the nurse believes that any sick person who needs care should receiye care whether or not he can afford to pay for it. In addition, the nurse tends to resent the notion of "red carpet" treatment as a suggestion that she would give superior care to a patient merely because he could afford to pay for it. The physician and the administrator are rarely in conflict over the affluent patient, but they sometimes come into conflict over a 71 patient who cannot be expected to pay his bill. These conflicts occasionally become disputes about the right to decide whether or not a particular patient should be hospitalized. The right to decide when a sick person is to be hospitalized is firmly located within the physician‘s decision-making territories. The responsibility for keeping the hospital solvent belongs to the hospital administrator. This division of responsibility and authority breeds an interesting battle . . . Medical domination over hospital-based care in conjunction with the big-business image of the hospital developed rapidly over the next decade. The cost reimbursement system, as inaccurate and inflationary as it was, remained the basic reimbursement system for hospital care. Carolyne Davis (1984) described the financing of hospital care as follows: The method by which we have been paying for hospital care, cost-based reimbursement, rewards hospitals for spending more. Retrospective payment for services puts most of the financial risk on the payer and provides the hospital with an incentive to maximize utilization. This situation also stimulates excessive inflationary growth. On the national level, this has meant growing federal expenditures and a rapidly increasing portion of the gross national product going toward health care, much more than the law and policy makers of the 19605 had anticipated. Congress and the Administration chose hospital reimbursement as its first effort to rescue Medicare because over two-thirds of 72 program outlays are spent on inpatient hospital care. In addition, as stated earlier, negative incentives had provoked unrestrained growth, and system reforms to change these incentives had to be made. Hospital reimbursement reform alone will not correct the situation, but it is the first step, and it halts a perverse consumption of public monies. The cover story in Business Week (July 25, 1983) portrayed the out-of- control health care costs this way: Pressures for change have been building in the health care industry for more than a decade as one Administration after another has attempted to control the costs of medicare and medicaid. All sorts of schemes have been tried-~limiting hospital construction, encouraging formation of HMOs, and cutting the government’s share of the hospital and doctor bills run up by medicare patients. Nothing has worked. Health care costs soared 11.9% in the US. last year while the consumer price index rose only 3.9%. The prospective payment system was designed to reverse the existing pattern of incentives, which said the more you spend, the more you will be reimbursed. Under the new system the incentives would be to manage costs. The new reimbursement system was likely to produce an upheaval in health care greater than any yet experienced; force redirection of provider, payor, and patient; and bring to the forefront extremely difficult moral and ethical questions. 73 Davis (1984) outlined the essentials of the prospective payment system as follows: Under prospective payment, Medicare payments for hospital inpatient operating costs will be made at a pre-determined rate for each case. Discharge cases will be classified into one of 468 categories by type of diagnosis. The diagnosis related group (DRG) payment rate will be payment in full except for capital- related costs, direct and indirect medical education costs (which includes nurse training), kidney acquisition costs, exceptional care required for outlier cases, and bad debts of Medicare patients. Rates will be calculated separately for urban and rural areas, and adjusted for area wage levels. The costs listed above are not included in the rate and will be paid separately as a cost-based ”pass-through." The nursing literature contains numerous articles describing the prospective payment concept and its implementation through diagnostic related groups (DRGs). There are also articles identifying the implications of this reimbursement approach for the health care system, nursing service, nursing education, and nursing research. That literature will be referred to as appropriate throughout this monograph. Factors Influencing Undergraduate Curriculum The specific focus of this monograph is the impact of DRGs upon the undergraduate nursing curriculum. I have modified that to include the 74 prospective payment concept as well as the DRG model. In reflecting on this topic and selecting a framework for this paper I developed the following abstraction of the factors influencing the undergraduate nursing curriculum. The figure is not meant to be an exhaustive listing of all factors influencing the curriculum nor a portrayal of all the interactions among those factors. It is simply an abstraction of reality to highlight those factors relevant to the purpose of this paper. The abstraction is meant to highlight (a) the many, complex factors influencing the undergraduate nursing curriculum; (b) the indirect impact of health care financing on the nursing curriculum; and (c) the potential for conflict between the educational system and the health care system regarding the curriculum. The two other monographs in this series describe the interactions and consequences portrayed in the box at the top of Figure l. Briefly, it is my observation that for people dependent on insurance financing of health care, their insurance will influence who will receive care, what care they will receive, where they will receive the care, and by which provider. For the rich and the uninsured poor, the effect of insurance coverage varies. Because of the tremendous number of people depending on insurance financing of health care, those decisions of who, what, where, and by whom tend to drive the health care delivery system. In that manner demands for providers and settings are increased or decreased. This chain of events has a direct and indirect impact on the undergraduate nursing curriculum. It has a direct effect in that the health care system is the 75 SOCIAL - POLITICAL ENVIgONyENT z"“. r’ \\ /“"'T"\ , NeaTth \ / HeaTth , Demands \ . Care I <-->l Care <--> .for Provider? \Financingl \Services \and Setting; \ / \ , \ ~ ...... / ‘ -_, HEALTH EAR: SYSTEM \/ Undergraduate Nursing Curricqum \/ SOCIAL - POLITICAL ENVIRONMENT I / ‘ r \ I \ I Nursing \ 1 Student \ [Education <-->§ Demand ;<--> (Financing \ / \ \‘a’ EDUCATION SYSTEM _‘ I ——————— / \ /Facu1ty Va'lues‘| ProfessionaT \ Standards , \ J -a FIGURE 1. Education I Abstraction of Factors Influencing Undergraduate Nursing n The Context of Prospective Financing of HeaIth Care. 76 learning laboratory for nursing students. It will therefore make available or unavailable various clinical experiences for teaching-learning opportunities. The indirect influence is through the market place and employer demand for nurses with particular knowledge, skills, and experiences. The box at the bottom of Figure 1 identifies factors within the education system impacting on the nursing curriculum. As these factors are not the focus of the other monographs, they are discussed in more detail. Funding for Nursing Education The financial resources available to a school of nursing have a strong impact on the nursing curriculum. For at least the last forty years controversy has existed over the roles of the state government, federal government, and private sector in the financing of nursing education. The Institute of Medicine report (1983), Nursing and Nursing Education: Public Policies and Private Actions, describes the situation this way: Before World War 11, nursing education, with a few exceptions, was largely the responsibility of the private sector. Nursing education took place almost entirely in hospitals,- often in an apprentice-type mode where formal and informal instruction of students was exchanged for the students’ services in patient care. At the same time, however, schools of nursing in a few universities were establishing the models that education for RN's 77 would follow in the postwar period, when it largely moved out of hospitals and into institutions of higher learning. Since World War 11, nursing education has been increasingly supported by state and local tax dollars as the number of diploma programs (almost entirely private) dwindled and the number of AD programs in community colleges (almost entirely public) soared. Since 1970, the proportion of baccalaureate nursing programs has remained almost evenly divided between private and public colleges and universities. The most visible source of federal support for nursing education is the Nurse Training Act administered through the Division of Nursing. However, funds available through the Nurse Training Act are dwarfed by allocations to hospitals for nursing education through Medicare programs administered by the Health Care Financing Administration (HCFA). Using data supplied in the Institute of Medicine Report (1983), Nursing and Nursing Education: Public Policies and Private Actions, and the Abt Associates (1979) report Effects of Federal Support for Nursing Education on Admission, Graduations and Retention Rates at Schools of Nursing, in 1979 (the only year for which comparable data were available) the federal government awarded $23.6 million for support of basic nursing education. That same year, the federal government awarded hospitals approximately $350 million for nursing education. The prospective payment legislation excluded the costs of educational programs in the DRG rate itself but allowed those costs as a pass-through. 78 That is to say, those costs could be passed through to the federal government. The final prospective payment legislation regulations specified that only educational programs operated directly by the hospital were eligible for funding. The largest portion of Medicare pass-through monies are used for medical education, particularly physician residency programs. Controversy continues regarding the amount and distribution of pass- through monies. Some would like to see them eliminated whereas others propose redistribution. Congress is in the process of obtaining data on the distribution of those funds to educational programs other than medicine. Those data appear difficult to isolate. Bullough (1985), commenting on the policy implications of the pass- through funds associated with the prospective payment legislation, stated: . . . the nursing profession needs to make decisions about the policy positions to be taken. How should nursing education be supported in a restructured system? What level(s) of nursing education should receive support? If subsidies are continued under the Medicare program or a similar mechanism in which the primary mission of the program is service to the patient, what will be the position of nurse educators regarding funding for nursing education that is based on service provided, such as the current funding mechanism for interns and residents? How can the nursing profession agree on these and other related issues to present a united front in these deliberations and negotiations? 79 Student Demand Student demand also impacts the nursing curriculum. At an aggregate level, student demand is an indication of the degree of congruence between the public image of the profession of nursing and the traits, values, aspirations, and expectations of students entering the postsecondary institutions. At a school level, student demand is an indication of the degree of congruence between the public image of that nursing education program and the traits, values, aspirations, and expectations of the population served by that school. As most students who are interested in entering a nursing program have a choice of schools, the nature of the curriculum, the qualifications of the faculty, the reputation of the school’s graduates, the clinical facilities associated with the program, and educational costs are factors that influence student demand. At a national level, student demand for admission into nursing education programs is taking the appearance of a "crisis." Green (1987) has described the "educational pipeline" picture as follows: The proportion of first-time/full-time freshmen women interested in nursing careers in all institutions declined by 50 percent between 1974 (the peak year) and fall 1986. The decline in the proportion of freshmen women interested in nursing careers masks a larger decline in the actual number of freshmen women interested in nursing careers. In fall 1986, 19,800 freshmen women hoped to pursue careers in nursing, down from 28,500 in 1985, 35,400 in 1984, 42,200 in 1983, and 40,316 in 1974. 80 In universities, there has been a 70 per cent decline in the proportion of freshmen women interested in nursing careers during this same period (from nine to two percent). In 1986-1987, the number of freshmen women in four-year colleges and universities planning to pursue medical careers is larger than the number of women interested in nursing careers by more than 5000 students. The ratio of aspiring women nurses to aspiring women physicians in the freshmen population has dropped from just over 3:] in 1968 to just under 1:1 (0.8:!) in l986; this shift in women’s aspirations marks a dramatic reversal in the health care field. His depressing summary is that there is a marked decline in interest in nursing careers and that decline is most marked‘ in the academically able women. Green, drawing an analogy to the field of education, identified improvement in salaries despite increasing pressures to control personnel costs through DRG limitations as an important first step inincreasing student demand. At this point in time, comparative data are not available for schools having no recruitment problem and those having recruitment programs. Such data would be helpful at a local level in particular. Faculty Values and Professional Standards The undergraduate nursing curriculum represents a particular“ faculty’s view of the theoretical and clinical content essential to ensure a safe 81 first-level practitioner. Although undergraduate nursing curricula across the country probably have many common components, they also have unique features. The curriculum is guided by expectations of society and other health care professionals but‘the selection and sequencing of content and experiences reflects the values and strengths of a particular faculty and the financial and clinical resources available. At one point in time an undergraduate nursing curriculum could be described in terms of ”the" six specialty areas: medical nursing, surgical nursing, pediatric nursing, maternity nursing, psychiatric nursing, and public health nursing. A student would receive instruction in basic nursing arts and then rotate through the specialty courses. That program of studies produced a generalist-~somebody safe to practice in any clinical area. Today's undergraduate nursing curriculum is more complex, reflecting the growth in scientific knowledge and technology, the subspecialization in clinical practice, and the diversification of the health care delivery system. Today’s nursing "generalist" is expected to be a safe first-level practitioner in respect to community health care, family health care, care of the child/adolescent in illness and health promotion, care of the ill adult and aged with emphasis on psychosocial factors, care of the ill adult and aged with emphasis on physiological factors, health promotion in the adult and aged and with family units including pregnancy care, care of the chronically mentally ill, and care of the chronically ill in rehabilitation. In addition, this generalist should be a safe practitioner in a hospital or 82 nursing home institutional setting, home, school, community, and industrial noninstitutional setting. In addition, this generalist is expected to have interpersonal skills, management ability, knowledge regarding the conduct and utilization of research, and a broad base in the legal, ethical, economic, and political forces affecting today's health care system. Faculty in schools of nursing feel a great deal of stress as they attempt to accomplish this in the limited academic credits allocated to the nursing major. (For further detail, see Essentials of College and University Education for Professional Nursing, American Association of Colleges of Nursing, 1986.) Implications for the Undergraduate Nursing Curriculum The change to a prospective payment system from a cost reimbursement system for Medicare patients was met'with wringing of hands and predictions of financial disaster by many health professionals. To some it seemed that overnight price wars emerged between hospitals, providers were spending large dollars for advertisements,'and health care administrators were talking of survival in a constrained economic environment. Indeed, administrators, whose success depended on running a nonprofit business now had to learn to run a business in which profit and survival were synonymous. The first response was to lower costs through changes in the number and mix of nursing personnel. In addition, the patient without cash or adequate insurance coverage was carefully evaluated in terms of the 83 seriousness of the medical condition and the. financial position of the hospital. Not everyone received care at the first hospital contacted. As hospitals gained experience with the new reimbursement system, and administrators had time to assess organizational behavior under the perspective of the new reimbursement system, different responses for balancing the budget (including a profit margin) emerged. The following trends seem to be a lasting outgrowth of the DRGs. First, the scope of activities assigned to the nursing staff has increased to include functions once performed by nurses but which under the cost reimbursement system were assigned to separate departments. For example, in many hospitals respiratory therapy and intravenous therapy are once again nursing activities. In addition, nurses are assuming more responsibility for monitoring medical orders to ensure that unnecessary or untimely tests are not conducted. Nurses are also evaluating their own activities to ensure greatest productivity. In this regard, Sovie (1985) suggests that nurses consider using generic care plans and less time- consuming methods for documenting care. She notes that nurses spend up to 40 percent of their time documenting care. The use of nursing diagnoseSv-an approach to documentation that does not fit with the hospital’s system for classification and analysis under the new reimbursement system--may also be an inefficient use of human resources. The trend to increase the scope of clinical activities performed by the nursing staff seems firm. This trend has resulted in hospitals moving to an all RN staff and increasing the educational preparation of that staff. 84 Accountability for resource consumption is also a component of that trend. A second trend relates to the delivery of services and the setting in which care is actually delivered. The cliche for what has occurred in the acute care setting is the ”quicker-sicker” syndrome._ Any procedure that can be safely done in the ambulatory or home setting is now being done there. In addition, patients who receive care in the hospital are not admitted until they must be there and they are discharged as soon as possible. A person having surgery is not admitted until the morning of surgery rather than the evening before. In many instances the patient does not arrive until 30 minutes before the operation is scheduled to begin. The length of stay has also been reduced for surgical patients. This same phenomena is true of other clinical areas. For example, in some hospitals the mode for a maternity patient is 14 hours; in other hospitals a short-term option is available, which enables the mother and infant to stay 24 hours including labor and delivery time. Partly in response to the early hospital discharge phenomena but aided by recent developments in technology, the home is becoming the setting for providing services that require sophisticated medical technology. Patients discharged from the hospital who cannot be safely cared for in the home may well spend several days at a nursing home and then be discharged to the home. The issue of care for those who do not have insurance is part of this trend that is still not clear. States such as Massachusetts are working out plans for a tiered health care system that would guarantee some health care for all. The 85 trend that seems clear is that the hospital will have a smaller and different role in the delivery of health care with the home, industry, and nursing home assuming larger and different roles. We are still far from having a system for the delivery of health care, but that is the direction in which we are going. A third trend is to increase the accountability of health care providers for the consumption of resources within the health care system. All providers are required to examine productivity and to propose cost reduction strategies and improved efficiencies. Quality assurance is part of the accountability. Inherent in this trend are the moral and ethical issues associated with rationing of health care. The reality is that nurses are not able to give each patient all the nursing care they consider desirable or necessary. In some respects this is not new for nursing. It seems like there have never been enough nurses on a given unit at a given time to provide all the care that patients required. Even the patient classification and acuity procedures did not seem to produce staffing patterns that gave nurses time to do all the activities considered important by the nursing staff. However, it is clear that the rationing of nursing services has become more explicit under the implementation of the DRGs and that the individual nurse is accountable for the ethical and moral decisions made relative to the use of resources. These changes in the health care delivery system are met with great concern by the nursing education system. Some of the first exchanges between nursing service administrators and nursing education 86 administrators included restricting“student access to clinical facilities and charging schools of nursing for access to facilities by students. Both service and education expressed concern for the amount of time the nursing staff would have available for assisting with student experience. The emphasis on efficiency and costs seemed in conflict with the potential inefficiency associated with student clinical education. Nursing education administrators wondered where, in the light of the decreased funding for nursing education, they could find monies to pay for clinical access for their students. The shifts in the setting for delivering care also raised a further issue of cost; to shift more clinical experiences to the home setting might also increase the cost of clinical instruction as one faculty member would be able to supervise eight to ten students using high medical technology in homes geographically dispersed. The ideals the faculty felt as they created the curricula that were in place prior to the prospective payment system seemed out of context as nursing staff implemented shorter stays and new efficiencies in the hospital setting. At a more concrete level some implications of the DRGs for the undergraduate nursing curriculum include: 1. Faculty will need to examine the curriculum to ensure that it includes adequate learning experiences in those knowledges and skills being reincorporated in the scope of nursing activities. For example, are there adequate learning experiences in respiratory therapy? 2. Faculty will need to examine the role the hospital setting can 87 play in the education of undergraduate students. If one assumes that ~. students are to practice as knowledge workers upon graduation, their classroom and clinical studies must provide for understanding at both the conceptual and empirical level. For example, how does one teach wound healing in today’s hospital setting? If a student cares for the patient only during the time they are hospitalized, the student will never see wound healing. It may be that a larger number of clinical experiences will have to use the approach that maternity nursing faculty have used. Namely, they assign a student to a pregnant woman/family and the student cares for that woman/family prior to admission in the ambulatoryrsetting, in the hospital setting, and following discharge at home. Obviously thereare other considerations that would have to be weighed before such a change could be implemented for all clinical experiences. 3. Somewhat related to the previous point but coming from a different concern is the appropriateness of the acute hospital setting for undergraduate education given the "quicker-sicker" trend. The acuity level of patients in the hospital give it the appearance of one large intensive care unit. Beginning nursing students are not prepared for the complex medical and nursing requirements of these patients. They .will require clinical learning experiences in settings with less acutely ill patients. 4. Undergraduate curricula will have to include courses on the financing of health care, resource management, and ethical and moral issues inculcated in today’s health care system. Although some schools offer this content, the curriculum will require examination to ensure it is , 88 adequate for the current and projected situation. Every nurse, not just the nurse manager, is embroiled in the economic and ethical decision making. Every nurse is expected to identify efficiencies for the system. 5. Faculty will have to examine the undergraduate curriculum to determine whether content in the basic and medical sciences is adequate to enable the graduate to fulfill the expectation that he or she monitor the medical plan of care not only for clinical effectiveness but for cost effectiveness. 6. Students will require greater preparation through simulated experiences before learning in the real clinical setting. Trial and error learning in the clinical setting will have to be replaced by simulation and the real world setting used to perfect nursing practice. 7. The undergraduate curriculum will have to be examined in light of shifting job opportunities for new graduates. Although the nursing program is an educational experience, the expectation is that upon graduation graduates will be able to provide safe care in today’s clinical settings. An increasing number of new graduates will work in nursing homes, home health care, industrial clinics, and ambulatory care. Are they prepared for nursing practice in those settings? 8. The teaching strategies and instructional practices of faculty will require evaluation to determine if adequate attention is given to transfer of knowledge. It is obvious that not all desired learning experiences can be provided to undergraduate students. The content and experiences associated with the concept of the generalist developed earlier in this 89 monograph greatly exceeds the time available in an undergraduate program. Selecting the essential core of prototype content and experiences, and teaching with strategies that enhance transfer, is critical. 9. Arrangements for clinical learning experiences will require more planning between service and education. Change in the clinical setting will continue at a rapid pace. Hospital patient census will fluctuate and staffing will be closely regulated. Backup clinical units and experiences may be necessary for a sound education. Conclusion In the immediate aftereffects of the DRGs, faculty found themselves facing a range of challenges. ‘Patients are now admitted the day of surgery.‘ How can students obtain experience in preoperative teaching? How do students learn the psychosocial aspect of surgery? ‘Staff identified as clinical resource nurses (CNNs) always assisted with clinical instruction.‘ The CNN assigned to work with a particular student was sent to another unit due to census fluctuations. The student’s clinical had to be redesigned at the last minute. It wasn’t of the same quality. How do you plan clinical instruction under these conditions? ‘The hospital sent a bill for the equipment the student contaminated in the process of caring for a patient.‘ School of nursing departments aren‘t funded to handle such costs. What does one do with such costs? The current economic environment and social-political climate are such that conflict between nursing service and nursing education over the 90 undergraduate curriculum could be extremely damaging to the long-term goals of the profession for improved salaries, working conditions, recognition, and authority. Conflict from that situation can be reduced or managed if there is collaboration at the grass-roots level. Developing such collaboration will take time from already over-committed people. It will require intensive communication, frequent contact, and learning to work in each other’s shoes. The following points regarding collaboration seem apropos in light of the current economic environment and issues regarding the undergraduate curriculum. 1. Obtain commitment from top to bottom of organizational structure. Collaboration affects resource utilization. It should not be an undercover activity. Sell it throughout the organization. Be certain the top-level administrators are knowledgeable and supportive. 2. Carefully select partners. Many partners are available. What do you need/want out of the relationship? Where are you most likely to find it? . 3. Create strategic plan to accomplish goals. Unexpected events may lead to success for a few, but for most, hard work and planning are required. Identify goals and think through strategies to reach those goals. If collaboration is important, it is important that it be implemented well. 91 4. 5. 6. Have fun before conflict. Conflict is bound to be present as one probes values, beliefs, current and future roles, etc. If these disagreements surface before peopleknow each other as individuals, individuals will not be able to separate criticisms of ideas from criticisms of self. Relating in a fun situation where appreciation of self is communicated will be very helpful in relating during crisis. Exchange an ”in-house scholar" for an "in-house clinician." Try the arrangement on a small scale. Evaluate the experience. Build a better mousetrap. Commit to richness in diversity. ' Nursing, again as it seems to me, has a history of valuing conformity. If something is good, it must be good for all. This is played out in our jumping on the bandwagon and adopting practices that are often nothing more than cliches. As we move forward with collaboration, particularly in this era of limited resources, it seems important that we not urge conformity to a few so-called models of unification. Rather it seems a time to learn to value diversity and richness that comes from differences. Each service agency developing a collaborative model with a school of nursing will have some unique features, needs, and goals. Because it makes sense that form should follow function, it would therefore make sense that we would have many different models. 92 7. Formulate agreements on time-dated conceptions. Conceptions such as nursing, research, practice, etc., are really time-dated conceptions. As our knowledge base grows and develops, and as advances are made in the world around us, our understanding of the concepts just mentioned will change. It is therefore my proposal that as collaboration progresses between nursing practice and nursing education (and here I am referring to individual institutions and not the aggregate), there is agreement on the meaning of those terms--that a conception is indeed made explicit; but also that there is agreement that the conception is time-dated and must change as the world around us changes. 8. Do careful hi'ring. Warm bodies are just not good enough for the environment that we are now living in. Even warm bodies with high degrees are not adequate assurance that desired goals will be reached. Those selected for employment must share the values of the parent institution and in this instance on the unification of nursing practice and nursing education. I just read the philosophy statement from a department of nursing service in a major teaching hospital. It stated that the department’s role in nursing education was to have administrators facilitate students’ access to the clinical setting. Staff nurses, head nurses and other nursing personnel apparently had no role in the 93 educational process. I was shocked. It is my recommendation that a clear commitment be made and expressed at the time of hiring all new faculty and all new nursing service personnel and if they do not support the goals of collaboration, they should not be hired. 9. Engage in joint programming. By pooling our resources and using them to serve the diverse needs of both nursing practice and nursing education, we will all get more for our dollar. Clinicians can enrich the academic setting. Faculty can enrich the clinical setting. Clinicians and faculty can share expertise in developing and implementing research projects. And, there is tremendous need for continuing education. Our knowledge base has such a short life span. All of us must view ourselves as lifetime learners. Continuing education is vital to our ability to function safely and with a vision of the future. The sharing of resources for our own lifetime learning is benefit from unification. l0. Take the offensive: Develop a database. The current environment of budget cuts and limited resources will increase the need for data from which policy can be developed. Administrators will need data; nurse educators will need data; the nurse at the bedside will need data. It will be essential to find more cost-effective approaches. Nurses might have been able during this last era of health care to ignore 94 research into nursing practice; THIS IS NO LONGER TRUE. Data will drive the era that we are moving into. As service agencies select partners in terms of schools to work with, the schools' potential to assist in research development efforts should be considered. 95 REFERENCES Abt Associates (1979). Effects of federal support for nursing education on admission. graduations and retention rates at schools of nursing. Washington, DC: Author. American Association of Colleges of Nursing (1986). Essentials of college and university education for professional nursing. Washington, DC: Author. 'Bullough, B. (1985). Public Policy: Medicare funding for nursing education. Journal of Professional Nursing, 1(1), 7, 64-65. Business Week (1983, July 25). The upheaval in health care: Government cost controls will soon have hospitals under the knife. Cover story, pp. 44-45. Davis, C.K. (I984). The status of reimbursement policy and future projections. In Nursing research and policy formation: The case of prospective payment (pp. 17-23). Kansas City, Missouri: American Academy of Nursing. Green, K.C. (1987). The educational "pipeline" in nursing. Journal of Professional Nursing, 3(4), 247-257. Institute of Medicine (1983). Nursing and nursing education: Public policies and private actions. Washington, DC: National Academy Press. Sovie, MD. (1985). Managing nursing resources in a constrained economic environment. Nursing Economics, 3, 85-94. - Taylor, C. (1970). In horizontal orbit: Hospitals and the cult of efficiency (pp. 19-20, 23, 34-45). New York City, NY: Holt, Rinehart and Winston. 96 THE QUESTIONNAIRES: NURSING PRACTICE AND NURSING EDUCATION Introduction Two questionnaires were developed and distributed to obtain regional data on the influences of prospective payment systems, particularly DRGs, on nursing programs leading to initial licensure and on nursing practices in institutional and community health settings. The cover memo, the information sheet, and questionnaire sent to schools appear on pages 98- 100, and to agencies on pages 101-103. Data from the questionnaires were analyzed and the results are reported herein. Development of Questionnaires In 1984, the American Association of Colleges of Nursing_(AACN) developed a questionnaire to determine deans’ perceptions of how DRGs influenced their baccalaureate nursing programs. In 1985, the AACN sent a different questionnaire to the l984 senior student participants one year after graduation to determine if DRGs influenced nursing at their place of employment (AACN, 1986). The AACN gave permission to WIN to adapt and use the question- naires. The AACN questionnaires served as the basis for the two WIN questionnaires. Several items were divided into two separate items and items were added. The AACN questionnaires asked for a yes/no response whereas the WIN questionnaires included a four point rating scale: none, slight, moderate, and substantive. The AACN asked the respondents to 97 WESTERN INSTITUTE of NURSING no. Drawer r 0 Boulder. Colorado 0 80301-9752 (303) 497-0242 September 10. 1987 I E I 0 R A I D U I To: Deans/Di ctors of Schoois Nursing in the Nest ’;;;ZE:‘Ld&-¢—-/€7’/<22L1\.v4«_¢ FROM: Jeanne. . earns. Executive Director 0n behaif of the Hestern Institute of Nursing. I request your assistance in providing information to us regarding the impact of prospective payment systems, particuiariy DRGs. on the nursing program at your schooi which ieads to initiai iicensure. The Western Institute of Nursing has received a purchase order from the Division of Nursing, Bureau of Heaith Professions. U.S. Department of Heaith and Human Services, to secure information concerning the impact of prospective payment systems, especiaiiy DRGs, on nursing care in institutions and in community settings. impiications for modification of ciinicai and didactic nursing courses in programs ieading to initiai iicensure wiii be identified. To accompiish the purposes. data wiii be coiiected from schoois of nursing and heaith care agencies in the west. and a regionai task force wiii be convened to examine issues and to make recommendations. The HIM-report wiii be sent to the Division of Nursing. The HXN report, aiong with reports from the other regionai groups (SREB, MAIN. and MARNA) which are carrying out simiiar studies. shouid be of vaiue to nurses and provide needed information for the Bureau of Heaith Professions reimbursement initiative. To assist us with data coiiection. piease compiete the enciosed information sheet and questionnaire. The questionnaire was adapted with permission from a previous one deveioped by the American Association of Coiieges of Nursing. Piease note you are asked to respond to the "present" and the 'future” in reiation to the pro- gramis) at your schooi which iead to initiai iicensure oniy. To provide the time needed to tabuiate and anaiyze the data, piease return the questionnaire and information sheet by October 5, 1987. The infonmation from aii respondents wiii be tabuiated. individuai responses from one schooi wiii not be identified. Thank you for your assistance with this important project.‘ mum $51M W MLW ir Ripple Nichols ' Juneau-ms %Aumman mumm ammundunw Dalmkhooidfluning dmcfledlcllccmu dedenmlovh TthregonHe-nh mum smoldnuning WWW Wimmnmmmq Maw"; Choir-um dbluornumm fiifiISfimnm Qasngiflnmlnzaz nuuVSmm mmmw . ”MN" Mood-ism , Wldmm Methane-don manarbrmm onwuuooISmnnancuuunh finflnaldmauuinenmtmem (cum-nun meunlfl(mi ‘ 98 llFORlATIOI ABOUT THE SCHOOL School T4: of 332a- Leading to --- n a censure Name Associate Degree Address Baccalaureate Degree it C y Student Enrolleents St e at Number of FTE Students Zip Enrolled during Academic Year 1986-87 Associate Degree Baccalaureate Degree Person coapletinggguestionnaire Name Title Telephone Number Confidentiality will be maintained. The above information will be used only for coding and analyzing purposes. Please return this sheet and the questionnaire to: Jeanne M. Kearns Executive Director Nestern institute of Nursing PO Drawer P Boulder. CO 80301-9752 (303)497-0243 Questionnaire to Determine Perceptions of the Present and Future llpacts of Prospective Payment Systems iDRGs) on Nursing Programs that Prepare for initial Licensure Directions 1. Please indicate the extent to which prospective payment systems, especially DRGs have and will influence the nursing program at your school. Place a check mark ( v’) in the appropriate column for both PRESENT and FUTURE for each item listed. 2. Nhen responding for the future, consider the next five years. 3. Each item is worded in the past or present tense. Nhen responding for the future. please as if it were worded in the future tense. 4. Return the questionnaire and the information sheet by October SI 1987 to: Jeanne M. learns Executive Director Nestern Institute of Nursing PO Drawer P Boulder. CO 80301-9752 (303)497-0243 99 consider the item lt-s Extent to which prospective oapent system (ones) have ratstlrtv mum the nursing program intent to which orosoective payeent systems - (lines) will effect the nursing program in the "I'M! (neat five years) bne Slight lioderate Substantial lone Slight Merate _ Substantial necessitated changes in clinical plat-nts 2. necessitated changes in clinical hours 3. Increased the muer of consecutive days of continuous tin in acute care settings Increased the niner of consecutive days of continuous tile in long- terl care settings Increased the nuoer of consecutive days of continuous N. in can”: health settings Ibre simlated clinical activities are used as the in-oatient hospital length-of-stay and population decreased 7. Increased ewhasis on hue care/ co-anity clinical experiences Increased eeonasis on geriatric clinical eaperiences Enhasis on the develop-ent of critical nursing skills for oatient care in cd-mity settings (ventilator care. chalotherapy ad-inistration. etc.) 10. Alteration in clinical reguir-ents; that is. abbreviated nursing care plans Increased ewhasis on co-anication stills Increased ewhasis on stills related to teaching clients Increased ewhasis on working eith clients and their faeilies as part of discharge planning Increased ewhasis on uorting with other health care providers or agencies as part of discharge planning Increased ewhasis on political] ecenoeic/legal issues in nursing curricula 16. liave instituted instruction for faculty and students to better prepare than for confronting ethical issues associated uith health care cost containent liave instituted instruction for faculty and students to better prepare th- for confronting econaic issues associated with health care cost contaimnt heed for faculty to be non directly involved in clinical practice to enhance their understanding of iwlications of health care econuics on Quality of nursing care Increased collaboration with nursing service agencies to better prepare nurses in caring for patients with shorter length-of-atays 20. Other (please soeci fy) *— -_—__ 100 WESTERN INSTITUTE of NURSING no. Drawer r 0 Boulder. Colorado 0 30301-9752 ‘ (503)4974I242 September 10, 1987 I E I 0 R A I D U I TO: Chief urse Executives of eaith Care Agencies in the Nest M It, . FROM: do, . Kearns, Executive Director— 0n behaif of the Nestern Institute of Nursing, I request your assistance in providing information to us regarding the impact of prospective payment systems. particuiariy DRGs, on nursing practices at your agency. The Nestern Institute of Nursing has received a purchase order from the Division of Nursing. Bureau of Hea1th Professions, U.S. Department of Neaith and Human Services. to secure information concerning the impact of prospective payment systems. especiaily DRGs. on nursing care in institutions and in community settings. Impiications for modification of ciinicai and didactic nursing courses in programs ieading to initiai licensure wi11 be identified. To accompTish the purposes. data wi11 be coITected from schoo1s of nursing and hea1th care agencies in the Nest, and a regionai task force w111 be convened to examine issues and to make recommendations. The NIN report wiii be sent to the Division of Nursing. The NIN report. aiong with reports from the other regionai groups (SREB, MAIN. and MARNA) which are carrying out simiiar studies. shouid be of va1ue to nurses and provide needed information for the Bureau of Heaith Professions reimbursement initiative. . To assist us with data coTTection, p1ease compiete the enciosed information sheet and questionnaire. The questionnaire was adapted with permission from a previous one deveioped by the American Association of Coiieges of Nursing. Piease note that you are asked to respond to the ”present" and the "future“ in re1ation to nursing at your agency. To provide the time needed to tabuiate and anaiyze the data, p1ease return the questionnaire and information sheet by October 5. 1987. The infonmation from a11 respondents wi11 be tabuiated. Individuai responses from one agency wii1 not be identified. Thank you for your assistance with this important project. loud dew-Iona W WM Lu“ “”3" Ir Ripple hem Nanci: Jeanne PI. Mums A um Mood-1e Dim Mood-u Dun olme (dupe ' MWdeflng URWCGMH dfluilhsdcncab'h TheOvepnna-iu‘ mum-um SandoMuMng 509m mug-n, W Caner a the University Univerflv aiming I'm dawns-hm 4me on! J. m... Wan-g.“ sew—H “nib-w W WW "5"" W" Aland-1e Director Mdmm mflmgm l manahmmm 3 “Hum" unannnwhuCum:muuuni mqmflm) 101 IIFDIIATIOI ABOUT THE AGENCY EIEEEZ Type of Agency = Acute Care Nospitai Nana Nursing Home Address , c::::2;ty Neaith City Size of Agency State Number of beds or Number of FTE Registered Nurse Staff Person convicting questionnaire Titie Telephone Number Confidentiaiity viii be maintained. The above information viii be used oniy for coding and analyzing purposes. Piease return this sheet and the questionnaire to: Jeanne M. Kearns Executive Director Nestern Institute of Nursing PO Drawer P Boulder. CO 80301-9752 (303)497-0243 ....................................................................................................... Questionnaire to Deter-ine Perceptions of the Present and Future Impacts of Prospective Pay-ent Systels iDNGs) on Nursing Practices at your Agency Directions 1. Piease indicate the extent to which prospective payment systems. especiaiiy DRGs have and viii infiuence the nursing practice at your agency. Piace a check mark ( J ) in the appropriate coiumn for both PRESENT and FUTURE for each item iisted. 2. Nhen responding for the future. consider the next five years. 3. Each item is worded in the past or present tense. Nhen responding for the future. piease consider the item as if it were worded in the future tense. 4. Return the questionnaire and the information sheet by October SI 1987 to: Jeanne M. Kearns Executive Director Nestern Institute of Nursing PO Drawer P Bouider. CO 80301-9752 (303)497-0243 102 Items Extent to which prospective payment systems (Dias) have '15!!!“ effected nursing at your agency intent to which prospective pay-lent systems (DRGs) will effect nursing at your agency in the Will! (next five years) Increased emhasis on hurting with clielts and their families as part of discharge planning None Slight Moderate Substantial lone Slight Moderate Substantial Increased whasis on sorting with other health care providers or agencies as part of discharge planning Increase in referrals for hone health care, or calamity health care follow-up Increase in referrals to long-tern care facilities Reduced nulser of in staff Increased under of in staff Less part-tine Iii staff Nore part-tine RN staff Reduced nueber of non-RN staff Increased number of non-RN staff Closing of patient care units as in-patient hospital census decreases Increased ewhasis on health promotion/disease prevention programs for consumers Increased need for nurses to partici- pate in political foru- and professional organization activities to increase nurses“ pouer base for influencing health policy decision—making Increased need for nurses to have continuing education in political, econonic. legal. and ethical fields Increase in direct or third party reiaoursenent to nurses for nursing services and/or health pronotion/ education services lie-admission of patients to acute care facilities men they lly have been discharged too early Separation of the cost for nursing services apart fro» the routine hospitalization charges billed a patient IB Decrease in staff nurse involve-lent with the education of, nursing students 19 Increase in staff nurse involvement uithghe education of nursing students 20. Decrease in fringe benefits (Please specify) 21. Other (Flease speciiyl 103 reply to the present, the WIN questionnaires had two parts, one pertaining to the influence at the present and the other to the influence in the future, which was defined as the next five years. Distribution The questionnaire for nursing practice was sent to 90 health care agencies in the west. Of this number, 39 were acute care facilities, 28 were community health care agencies, and 23 were nursing homes. The questionnaire for nursing education was sent to the 197 schools of nursing in the west, which offer 148 associate degree (ADN) programs, and 52 bachelor of science in nursing (BSN) programs. Returns A total of 27 health care agencies (30 percent) responded to the questionnaire. Of this number 16 were from acute care facilities, 8 from community health agencies, and 3 from nursing homes. Ten of the 13 western states were represented. (No returns from Alaska, New Mexico, and Oregon were included.) In addition to the 27 health care agencies, one hospital and one community health agency returned the questionnaire, each with a letter stating the agency was not under DRGs. One questionnaire from an acute care facility arrived too late for inclusion in the analysis. Questionnaires to four home health agencies and one nursing home were returned because of inaccurate addresses. Tables 1 and 2 show information on the agencies 104 TAIL! l: «(I N “SIC!“ IV "PE 07 AGENCY AND IV STAY! WAY IESFONOEO TO "IE WESYIMIAIIE YO DETERNXIE lNFLUENCE 0F PROSPECHVE PAYNE!" SVSYENS (DIG!) 0N NURSING KICEHIMS Of THE RESEIT AND FUTLRE PWICES State Acute Care nanny Co-unHy wealth sunny Nursing No- Total Huh - . . . hrizou 4 - - t mum-nu 7 - I l Conrado 2 - l 3 Mail" - 2 - 2 Idaho - - l 1 Montana 1 - - 1 land: - 2 - 2 In Nuico - - - - Oregon - . . . um I 2 - 3 Hashington l - - l "JO-"'9 - 2 - 2 You! 16 8 3 27 MILE 2: HUI“ Of “05 II THE INSTHUTIONS INA! RESPOND!!! 70 7M! OUESYIONNMRE Mr of led: Acute Care flcnuks harsh-g Mons 700 and Above 1 . 600 - 699 l . 500 - 599 l 1 400 ~ 499 l - 300 - 399 Z - 200 - 299 3 - 100 - 199 £ 1 bum mo 1 1 '70:“ 16 3 105 included in the analysis. A total of 107 schools of nursing offering 109 degree programs returned the questionnaires in time for inclusion in the analysis. The return rate from schools was 54.3 percent. The 109 questionnaires represented 72 ADN programs and 37 BSN programs. These programs represent 48.6 percent of the ADN programs and 71.2 percent of the BSN programs in the west leading to initial licensure. In addition, three ADN and three BSN programs returned the questionnaires too late for inclusion. Information on the schools included in the analysis is contained in Tables 3 and 4. Persons Completing Questionnaires For health care agencies. 66.7 percent of the questionnaires were completed by the chief nurse executive. For schools of nursing, 75.7 percent were completed by the clean or director or the assistant/associate dean or director. Information about the persons completing the questionnaires is contained in Tables 5 and 6. Data Analysis The data analysis was done on the SPSS computer program at the University of Colorado Center for Nursing Research. The "none" response was scored as 0, ”slight" as 1, ”moderate" as 2, and "substantial" as 3. Mean scores were determined. Ranges of mean scores were then assigned as follows: 106 nun U SONS of ”SING IV "I! OF mom AID IV 5'"! 1M! "SM“ 10 “I “mm": W "‘u 3: ITEM!!! KICIHINS U I’ll! RISE!" um Futllt "Full“ Of momma mum “SKIS (DIG!) 0N "SING nouns "I! "Hut '0! IIHIAL LICEIISUIE “or of norm Lucia: :0 Initial Human “or of I I or P ran Stu: 5cm“ of Nursing “"61"! Degree hccalaumu Huh I - l Amen: 5 3 2 CaHlov-Mu 43 so I! Cour-do 7' 4 0 mm q‘ a 2 Idaho 4 t - Mam ‘ 2 2 mm 1 o 1 In Ito-1:0 9 8 1 Dragon 7 o 3 Utah 2 l 1 Unknown N I 6 Nye-Mg 5 4 1 lot Defiant“ 1 1 . Ton! 109 7! 37 . 000 “Mo! ofhn both an undue «one and I bucfllurom «gm progn- ‘nflu to «mm "censure. "IL! I: * MIR 0! "I $1110!le EIIMLED II 1986-" ll MN MO IS! mm WAY "SM" TO THE WESTIWIAIII "I swam; Maxine Bum men-mm 500 and no" - l 450 - 499 l - ‘00 - us . 1 350 - m - z 300 - 3‘9 1 6 250 - 299 - ‘ 200 . 249 1 ‘ 150 - 199 6 I ma - 149 15 6 so - 99 2! 3 l9 and below 12 2 not mcgmm' 7 ‘ You} 72 )7 lnc‘udos than “Sign!“ in Mad count, and than that and.“ no {slow-flea. 107 TAILE S: TITLES Of PEISMS COOLETING QUEsTIWIIE 10 DETEMINE PEICEPTIMS or TNE PRESENT An FUTURE INFLUEICE G PROSPECIIVE PAVKNI SVSIENS (0110:) ON NURSING PRACTICE All Types of Agencies Acme Care toe-unity Nentn Nurs|ng Nune: Title liner Percent Nuwber Percent Nufier Percent HUME? Percen! CMef Nurse Executive 17 63.0 10 62.5 5 62.5 2 66.7 ”shunt/Associate 1 3.7 1 6.3 - — - - (”Victor Other 9 33.3 5 31.3 3 37.5 1 33.3 To!“ 27 100.0 16 100.0 a 100.0 3 100.0 TABLE 6: TITLES OF PERSONS CMPLETXNG OUESTIONNAXRE To DETERMINE PERCEPTIONS 0' THE PRESENT AND FUTURE INFLUENCE U PROSPECTIVE PAYMENT SVSTENS (01165) on NURSING PROGRAMS YNAT PREPARE m 11117101 LICENSUPE A11 Types 0! Progrus AUN Programs ISN Prunes 1m. Nuoer Percent Numer Percent lumber Percent Dun/01nd" M 77.1 64 08.9 20 53.1 Annunc/Associue 11 10.1 3 3.2 I 21.6 been or 01mtor Other 11 10.1 3 4.2 I 21.6 not deflgneted 3 2.0 2 2.3 1 2.7 Totn 109 100.0 72 100.0 37 100.0 108 None mean of 0.949 and below Slight mean of.0.950 to 1.949 Moderate mean of 1.950 to 2.549 Substantial mean of 2.550 and. above Mean scores were also converted to ranks with l assigned to the highest mean. Significant differences were determined by the use of a two-tailed t test. Significance was established at the probability level of p < 0.01. Data were analyzed for ADN and BSN programs combined, for ADN programs only, and for BSN programs only. Because the number of' responses from health care agencies by type of agency was small, the data analysis was reported on all types of agencies combined rather than by individual type of agencies. Influences on Health Care Agencies Results for the Present The items for the present, listed by rank, the mean scores and the ranges of mean scores are presented in Table 7. This table also shows the comparison of the present with the future for each of the items. No item was rated in the ”substantial" category for the present effects of prospective payment systems on agencies. The following three items were in the "moderate" range: Increased emphasis on working with clients and their families as part of discharge planning 109 1K! 7: ”58' ll puma 3mm: MPH” N M "(SM 4‘ F111“! “Full“ 0: PROSKC‘HVE MM!" SYSTERS (DIG!) 1N ALI. TYPES 07 “it!!! (um “I! mumls. mm M"! SIYHWS. NO M51746 ms) msm mun: ' 1 1 z I . we: to! nun: Ion Ill! It”! 500“ I‘M $60!! WK KM SCORE HEM SCORE 18mm 0.0551! 00 am... with 1 2.407 I 1 2.704' 50 cunt: and mm “-1110: u I!“ of “scum flaming lumso 1n nun-.1: hr hu- mm 2 2.269 M 3 2.654' su an. or c—muy health can "Hon-0' 1mm“! .0011: on north. rm. 3 2.259 n 2 2.667' 50 «Mr mm. are mm": or umm II urc 61 «scum phoning 10cm)“ and for mm: to have 4 1.926 5 4 2.556' 50 continuum «acute» 10 ”mun. none-1c. 10:01. 0nd "01:61 mm Incl-nu in rut-nah u Ion-ur- 6 1.640 s 6 2.292' u can mmcm Inc-mud and (or m: to vanish 6 1.773 s 5 2.407' a nu 1n 991111211 lon- IM "chum-:1 ”Manon «qu110; to {male wnu' pom sou for “flu-ad" mm policy incision-cling Increased an“: on mm 7 1.423 5 7 1.962' N "noun/dun" pmonuon program Mr consular: luv-nu in um um huh—n: 0 1.200 s 9 1.640' 5 an 100 education 0' mm flaunt: lnmuod Inner of I11 :1." ‘ 9 1.154 5 11 1.500 S Iowans!" of ”that: to acute 10 1.111 5 12 1.259 s can 0:111:10: when they any have but: «scum-d 100 only Inert-mi nub" o! non-ll "a" 11.5 0.046 N 1: 1.231' s ’0" DIN-"- III In" 11.5 0.546 I 14 1.120 5 lncruu in direct or tMrd party 13 0.720 I 6 1.950“ N "1.1mm“ to nurse: for nursing "Men Ind/or mm pro-ouch] mention urvicu mu“ odor of non-I11 su" 14 0.640 I 16 0.609 N cum. of onion: an 0011: u 15 0.619 I 15 1.048' 5 1mm": hospiuI consul “emu: Sop-nun» of the cost lor nursing 16 0.542 n 10 1.545' s urvlcu nut Ir. "a mum mummmn cums 6111.11 a patient ‘ have“ M." of I11 nu" 17 0.300 I 15 0.417 N 00cm" in him Mafia 1! 0.260 n 17 0.480 N Mm» h m" nurse Cumin-Int 19 0.250 I 19 0.250 N '11» 1M oduutlon of mm». students Lu: Dart-1‘- III “I" 20 0.083 N 20 0.217 N In». Interweave can for m run." tor nan Icons: 11 . lone It.» 0' 0.949 and M10- 5 - 511901 In» 07 0.950 1.0 1.049 I I Mute lbw 07 1.950 to 2.549 50 - Sublunzm Nun of 2.550 and than a 1' 27 (16 acute can mum“. I cum” Mimi settings. 3 wrung Man.) ' g < .01. tun-141106 .. mm mm: and future 110 Increase in referrals for home health care, or community health care follow-up Increased emphasis on working with other health care providers or agencies as part of discharge planning The following seven items, listed in rank order, were in the ”slight" range: 4, Increased need for nurses to have continuing education in political, economic, legal, and ethical fields Increase in referrals to long-term care facilities Increased need for nurses to participate in political forum and professional organization activities to increase nurses‘ power base for influencing health policy decision making Increased emphasis on health promotion/disease prevention programs for consumers Increase in staff nurse involvement with the education of nursing students , Increased number of RN staff Re—aidmission of patients to acute care facilities when they may have been. discharged too early The ten items in the "none" range, listed in rank order were: Increased number of non-RN staff More part-time RN staff Increase in direct or third party reimbursement to nurses for nursing services and/or health promotion/education services Reduced number of non-RN staff Closing of patient care units as in-patient hospital census decreases Separation of the cost for nursing services apart. fromthe routine hospitalization charges billed a patient Reduced number of RN staff 111 Decrease in fringe benefits . Decrease in staff nurse involvement with the education of nursing students Less part-time RN staff Thirteen individuals included comments. These comments indicated that there is a need to increase RN staffing and to decrease non-RN staffing; however, the nursing shortage may dictate the reverse. Separation of costs for nursing service and an increase in staff involvement with the education of nursing students have occurred in one institution but neither was related to DRGs. Staff benefits have been increased to promote retention and recruitment of nurses due to the shortage. DRGs have increased nurse/physician collaboration and decreased budgets for supplies and capital equipment. Results for the Future and Comparison with the Present The mean scores for 18 items were higher for the future than at the present (see Table 7). The mean score for one item decreased (reduced number of non-RN staff) and for one item remained the same (decrease in staff nurse involvement with the education of nursing students). Both of these items were “in the "none" range for both the present and the future. Three items that were in the "moderate” range at the present were in the "substantial" range for the future. The differences were significant. Those items were: Increased emphasis on working with clients and their families as part of discharge planning 112 Increased emphasis on working with other health care providers or agencies as part of discharge planning Increase in referrals for home health care, or community health care follow-up The item that increased significantly from the ”slight” range at the present to the "substantial" range for the future was: Increased need for nurses to have continuing education in political, economic, legal, and ethical fields The three items that increased significantly from the ”slight" range at the present to the ”moderate" range for the future were: Increased need for nurses to participate in political forum and professional organization activities to increase nurses' power base for influencing health care policy decision making Increase in referrals to long-term care facilities Increased emphasis on health promotion/disease prevention programs for consumers The one item that increased significantly from ”none" to the "moderate" range was: Increase in direct or third party reimbursement to nurses for nursing services and/or health promotion/education services The three items that increased significantly from "none" to the "slight" range were: Separation of the cost for nursing services apart from the routine hospitalization charges billed a patient Increased number of non-RN staff Closing of patient care units as in-patient hospital census decreases 113 One item with a significant increase remained in the "slight” range: Increase in staff nurse involvement with the education of nursing students Although not significantly different, the increase in the mean score for one item moved that item from "none" at the present to ”slight” for the future: More part-time RN staff The two items that remained in the "slight" range were: Increased number of RN staff Re-admission of patients to acute care facilities when they may have been discharged too early The five items that were in the "none" range for both the present and the future were: Reduced number of non-RN Staff Decrease in fringe benefits Reduced number of RN staff Decrease in staff nurse involvement with education of nursing students Less part-time RN staff Comparison of AACN Results with WIN Results The comparison of the results from the AACN study (AACN, 1986, p. 9) with the WIN results indicates that for almost all comparable items, the influence of DRGs on nursing practice has dramatically increased from 1985 to the present and should continue to increase into the future (1992). 114 Sixty-one percent of the respondents to the I985 AACN questionnaire indicated that DRGs increased referrals to home care and long-term care. In responding to the present, 96 percent of the respondents to the WIN questionnaire indicated that such referrals have increased. For the future, 96 percent of the WIN respondents indicated home health care referrals will increase and 100 percent indicated that long-term care referrals will increase. An increase in discharge planning was identified by 52 percent of the AACN respondents and 100 percent by the WIN respondents for both 1987 and 1992 In l985,only 29 percent ofthe respondentsindicated the need for continuing education in political, economic, legal, and ethical fields. For 1987 and 1992, 100 percent of the respondents indicated this need. Similarly, only 24 percent of the respondents in 1985 indicated the increased need for nurses' political involvement or participation in professional organizations to influence health care policy. For 1987, 89 percent of the respondents so indicated, and for I992, 93 percent indicated the need. For 1987 and 1992, 78 percent of the respondents indicated readmission of patients who were discharged too early. This percentage was up from 47 percent in I985. Increased emphasis on health promotion programs went from 41 percent ofthe respondentsin l985to 79 percentin I987 and 93 percent in 1992. 115 The closure of units increased slightly from 44 percent of the respondents in 1985 to 47 percent in 1987. For 1992, this increased to 57 percent. The items related to staffing showed a different trend. In 1985, 36 percent of the respondents perceived a reduction in full- time registered nurse staff and in non-RN staff. For 1987, 19 percent of respondents perceived a decrease in RN staff, and 36 percent of the respondents in non-RN staff. By 1992, 25 percent of the respondents perceive reductions in RN staff and 30 percent in non-RN staff. Influences on Nursing Education Programs Results for the Present The ranks, mean scores, and interpretive codes for the range of mean scores for each of the items by ADN and BSN programs combined, by ADN programs only, and by BSN programs only for the present are contained in Table 8. The present effects of prospective payment systems on ADN and BSN programs were "slight" to "none". No item had a mean score in the ”moderate" or "substantial" range. It should be noted that some respondents indicated that changes have been made in programs, such as increasing geriatric experiences, but that forces other than DRGs have brought about the changes. Several questionnaires from ADN programs indicated that community health was not included in the program at the present but reference was made to the 116 "ll! 8: 10 llilllN, UCEISWI NW5! EOLCMMS' PERCEPHNS 0' "it ”(SEN IM’LUINCE 0f PIOSPEUIVI PAYNE!" S'SlEHS (01165) N NURSING PROGRAMS lull LUD mx WISE roe HEM $600! M0 HEM SCORE l 1 E Ii 0011 0 050 b ‘ m I ma 00011120. we Our ssn our cos-Into ADI! 016.1 050 ouu lncreesed ewnasis on sorting eitn 5 5 5 clients end their iuilies es oert oi discharge planning 1 l 4 1.407 1.437 1.351 Increased eqnosis on political] 5 5 S econoeic/legol issues in nursing curriculu- 2 3.5 1 1.3” 1.310 1.514 lncreesed ewnesis on sorting with S 5 5 other neoltn care providers or egencies es pert oi discharge olenning 3 3.5 6 1.299 1.310 1.270 1ncreesed ennssis on skills related 5 5 S to teaching clients 4 2 10 1.250 1.952 1.054 lncreesed collsboretion eitn nursing s 5 5 service sgenciss to better oreoere nurses in caring ior utients eitn 5 5 5 1.240 1.222 1.297 snorter length-oi-steys Increased ewnasis on geriatric S 5 S clinicel experiences 6 6 3 1.170 1.071 1.361 Nave instituted instruction ior 5 S S isculty and students to better prepare the for confronting ecomic issues associated with 7 9 7 1.074 0.906 1.203 nealtn core cost contairnsnt iisve instituted instruction ior S 5 5 ieculty and students to better prepare tnee ior confronting 0 7.5 I 1.065 1.000 1.109 ethical issues associated with health csre cost contain-Mt 1ncreesed mitosis on no- core] 5 I s cununity clinicsl experiences 9 11 2 1.009 0.000 1.405‘ necessitated changes in clinicsl 5 S N oIacsnents 10 7.5 12 0.963 1.000 0.092 Need ior isculty to be more directly involved in clinical oractice to Ii I N enhance their understanding oi ieolicstions of Main core economics 11 12 11 0.024 0.761 0.946 on quality oi nursing care tunesis on tne develop-em oi criticel nursing stills ior patient ii I 5 care in con-unity settings (ventilator care. cn-otnerapy stinistration. etc.) 12 15 . 9 0.002 0.623 1.135' increased eeonasis on co-unicstion u u u stills 13 10 13 0.790 0.006 0.704 A1teration in clinical reguir-ents; u I N tint is. abbreviated nursing core plans 14 14 14 \ 0.670 0.639 0.730 ibre sieulated clinical activities ere used es the in-oatient nosoital I I N length-oi-stey and population decreased 15 13 15 0.624 0.601 0.514 Necessiteted cnsnges in clinical l ii N hours 16 16 16.5 0.440 0.450 0.405 Increased the wiser oi consecutive l u N days of continuous tie: in cngnity neeltn settings 17 17 10 0.302 0.446 0.270 Increased the alder oi consecutive it n N dsys oi continuous ties in long- terI care settings 10 10 16.5 .0324 0.202 0.905 lncreesed the W? oi consecutive ii ii I days oi continuous ti. in ocute care settings 19 19 19 0.302 0.446 0.270 a .5-109 c5. 72 1'37 ' L < .01. M-uilu -- between ”I 0M ISM iiotes. Interpretive codes ior tne ranges ior non scores: I -'iione S 0 Slight ii - lbderete 50 - Substantial 117 Mean oi 0.949 and below Mean oi 0.950 to 1.949 than oi 1.950 to 2.549 Neon of 2.550 and above possibility of including this content in the future. A total of 23 respondents included comments on the questionnaire. Of all the 19 items, significant differences were noted between ADN and BSN programs for two items. The means were in the "slight" range for BSN programs and in the ”none" range for ADN programs for the following items. Increased emphasis on home care/community clinical experiences Emphasis on the development of critical nursing skills for patient care in community settings Eight items were in the “slight" range for both ADN programs and BSN programs. These items listed by rank from the mean scores for ADN/BSN programs combined are: Increased emphasis on working with clients and their families as part of discharge planning Increased emphasis on political/economic/legal issues in nursing curriculum . Increased emphasis on working with other health care providers or agencies as part of discharge planning Increased emphasis on skills related to teaching clients Increased collaboration with nursing service agencies to better prepare nurses in caring for patients with shorter length-of-stays Increased emphasis on geriatric clinical experiences Have instituted instruction for faculty and students to better prepare them for confronting economic issues associated with health care'cost containment Have instituted instruction for faculty and students to better prepare them for confronting ethical issues associated with health care cost containment 118 For ADN programs, the following item was in the "slight" range, and i {or BSN programs in the ”none" range: Necessitated changes in clinical placements The eight items listed by rank from the mean scores for the ADN/BSN combined that were in the "none” range for both ADN and BSN programs were: Need for faculty to be more directly involved in clinical practice to enhance their understanding of implications of health care economics on quality of nursing care Increased emphasis on communication skills Alteration in clinical requirements; that is, abbreviated nursing care plans More simulated clinical activities are used as the in-patient hospital length-of-stay and population decreased Necessitated changes in clinical hours Increased the number of consecutive days of continuous time in community health settings filncreased the number of consecutive days of continuous time in long- term care settings Increased the number of consecutive days of continuous time in acute care settings Results for the Future and Comparison with the Present The ranks, mean scores,~and interpretive codes for the range of mean scores for each of the items by ADN and BSN programs combined, by ADN programs only, and by BSN programs only for the future are contained in Table 9. Table 10 contains the present and future comparison of ranks, 119 lhlu.’ 9: III!“ [0001099 PEICSPIIOIIS OF Int iuluil INFLUENCI or vnosvmm "mm SvSltnS (0R0!) 0N IURSING PROGRAMS INA! LEAD To Infill. LICEllsult um: W6! "I MEAN 550*! M0 MEAN SCORE I 1 s n we a ssn b ‘ A0" I IS“ counts). we own use osu cullntn we Mi use can Increased ewhasis on snorting with H II M clients and their ia-ilies as part oi . ‘ifimm punt" I 2 I 2.12“ 1.0.3. 1.273' Increased ewhasis on sorting with , H N " other health care providers or agencies as part oi discharge planning 2 A S 2.0CO' I.995' 2.167' Increased ewhasis on geriatric Ii n n clinicel superiences 3 2 7 2.030' 1.043' 2.020' Increased ewhasis on skills related In Ii Ii to teaching clients . 9.5 2 9 2.020' 1.043' 2.000' Increased mum on political/ N 5 " econuic/Iegsl issues in nursing curriculu 9.5 5 2 2.020' 1.913. 2.2‘3' Increased collaboration with nursing N 5 " service apencies to better prepare nurses in caring ior patients with 6 5 S I.9SJ' 1.910 2.05" shorter length-oi-stays Increased eqhssis on hone care/ 5 S I co-anity clinical experiences 1 lo 3.5 1.070' 1.704' “ 2.199' luvs instituted instruction ior faculty and students to better 5 5 " prepare than ior conironting econunic issues essocisted with I d 0 I.050' 1.757' 2.027' health care cost contaiment have instituted instruction for isculty and students to better 5 S S prepare th- ior conirpnting ethical issues associated eith 9 7 10 1.021' 1.197' 1.065' health care cost contain-nt lecessitated changes in clinical S S S plac-nts Io 9 II I.195' 1.7.? 1.750' [aphasia on the develop-mt of K critical nursing skills for patient S S M care in co-anity settings (ventilator care. chentherapy abinistration. etc.) 11 II 3.5 I.660' 1.377' “ 2.189' heed ior iaculty to be um directly involved in clinical practice to S S S enhance their understanding oi iwlications of health care econoeics 12 13 12 1.307' 1.30“ 1.541' on NIH” oi nursing care Increased ewhasis on co-anicstion S S S stills 13 12 ll 1.300‘ 1.329' I.270' Alteration in clinical requir—ents; S S 5 that is. abbreviated nursing care plans It It 13 1.290' 1.271' 1.32" Ibre sinlated clinical activities are used as the in-patient hospital 5 S S length-oi-stay and population ‘ decreased IS IS IS LIII' 1.239‘ 1.213‘ Necessitated changes in clinical S S S hours . IS 16 15 1.171‘ 1.129' 1.257' Increased the Inner oi consecutive S S 5 days oi continuous tine in ce-ncnity health settings I7 I7 I7 1.070' 1.095' 1.139' Increased the nufier oi consecutive S S 5 days oi continuous ti- in long- ter- care settings II II ' II 1.000' 0.975' 1.053' Increased the Inner oi consecutive ' Ii I u days oi continuous ti. in acute care settings I! I9 I9 0.09“ 0.030' 0.657' Iotes. Interpretive codes ior the ranpes ior nan scores: I - hone lean oi 0.949 and below 5 - Slight ban oi 0.950 to 1.999 ii - Moderate lien oi 1.950 to 2.519 . a Si! I Substantial linen oi 2.550 and above . 1- I09 . 1- 72 120 n - 57 L‘ .01. tan-tailed -- hat-seen present and iuture “ 1‘ .01. tee-tailed -- bet-eon Mall and IS! TABLE 10: THAI LE“) 10 "MIN. LICEISME NilSE EDUCATOR? 'ERCEPHONS 0‘ "it PRESENT AND FUTURE INFLUENCE OF PROSPECTIVE PAVMENT SVSTEHS (DIM) 0N NURSING PROGRAMS PRESENI EUTUIE 11E! MEAN SCORE “ICE '0! HEM SCORE RANK I!“ SCORE IANGE FOR MEAN SCORE Increased ewhasis on uorking with clients and their fa-ilies as part oi discharge planning 0 1.407 2.124‘ Increased ewhasis on political] econuic/legal issues in nursing curriculu- 1.380 2.020' Increased ewhasis on Iorking uith other health care providers or agencies as part of discharge planning 1.299 2.048' Increased enhasis on skills related to teaching clients 1.250 4.5 2.020' Increased collaboration with nursing service agencies to better prepare nurses in caring for patients with shorter length-oi-stays 1.240 1.963' Increased (”hash on geriatric clinical experiences 1.170 2.038' have instituted instruction for acuity and students to better prepere then ior confronting econo-ic issues associated with health care cost contaiI-ent 1.074 1.350' Nave instituted instruction ior faculty and students to better prepare the. ior confronting ethical issues associated with health care cost contaiI-ant 1.065 1.821' Increased eqhasis on hue care/ calamity clinical experiences 1.009 1.070' iiecessitated changes in clinical placuents 0.963 1.171' heed ior iaculty to be lore directly involved in clinical practice to enhance their understanding of iwlications of health care econuics on quality of nursing care 11 0.824 12 1.387' tnhasis on the develop-eat of critical nursing skills for patient care in cmnity settings (ventilator care. ch-otherapy abinistration. etc.) 12 0.802 1. 560‘ Increased ewhasis on co—micstion skills 0.798 1.308' Alteration in clinical reguiruents; that is. abbreviated nursing care plans 0.570 1.290' ibre simlated clinical activities are used as the in-patient hospital length-of-stay and population decreased 0.624 1.241‘ Necessitated changes in clinical hours 0.440 1.711' Increased the Mr of consecutive days of continuous tile in cmnity health settings I7 0.302 1.078' Increased the nDer of consecutive days of continuous tile in long- terI care settings 0.324 1.000' Increased the Inner oi consecutive days o1 continuous tile in acute care settings 0.302 19 0.638' ' g- we (72 aoa plus 31 ISO!) s. Interpretive codes (or the ranges Ver nan scares: ii I None 5 - Slight li - Moderate 50 - Substantial 121 g ‘ .01. too-tailed -- hetoeen present and future Mean of 0.949 and belou Hean of 0.950 to 1.949 Mean of 1.950 to 2.54! Mean of 2.550 and above mearl scores, and range of mean scores for ADN and BSN programs combined. This same type of information is contained in Table 11 for the ADN programs only, and Table 12 for the BSN programs only. The mean scores for all 19 items were higher for the future than at the present, although no item was in the "substantial" range. The differences were all significant. In total, 4 of the l9 items were in the "moderate" range for both ADN and BSN programs. These items listed in rank order from the mean scores for ADN/BSN programs combined were: Increased emphasis on working with clients and their families as part of discharge planning Increased emphasis on working with other health care providers or agencies as part of discharge planning Increased emphasis on geriatric clinical experiences Increased emphasis on skills related to teaching clients For BSN programs, five additional items were in the "moderate” range. These items, listed in rank for BSN programs only, were: Increased emphasis on political/economic/legal issues in nursing curriculum Increased emphasis on home care/community clinical experiences Emphasis on the development of critical nursing skills for patient care in community settings Increased collaboration with nursing service agencies to better prepare nurses in caring for patients with shorter length-of-stays Have instituted instruction for faculty and students to better prepare them for confronting economic issues associated with health care cost containment 122 1"! ll: ASSNMYE‘KCIE! m IRS! WY“? 'EICEPTIUS 0' "It "(SENT M rum: INFLUENCE 0' "03'“:le "Mill SVS‘IEHS (ORG!) Oii ”ml"! D“!!! "SI“ ”HIS "[50" 70100! I l E II we: FOR we: 704 MI! 11M SCORE "(All SCORE Mill KM SCORE HEM SCORE Increased enhasis on wrting with clients and their ialilies as part oi ‘ discharge planning 1 . 1.437 s 2 2.043‘ n Increased enhasiapn skills related to teaching clients 2 1.052 S 2 2.043' M Increased enhaeit on carting with other health care providers or agencies at part oi discherge planning 3.5 1.310 S 6 1.905' M Increased ewhasis on political] mic/legal issue: in nursing curriculue 3.5 1.310 S 6 1.911' S Increased collaborotion eith nursing service apencies to better prepare nurses in caring ior patients with 5 1.222 S 5 1.914' S shorter length-oi-stays lncreased ewhaais on geriatric clinical experience: 6 1.071 s 2 2.043' M iiave instituted instruction ior iaculty and ttudenta to better prepare th- ior conironting ethical iasuea associated with 7.5 1.000 s 7 1.797' 5 health care cost contain-ht Necessitated changes in clinical place-outs 7.5 1.000 s 9 1.743' s Iiave instituted instruction ior iaculty and students to better prepare thou ior confronting econooic issues associated with 9 0.986 s 0 1.757' 5 health care cost contaiment Increased mhasis on c-nnication lkills 10 0.006 N 12 1.129' 5 Increased eoohatis on ho- care/ cumity clinical experiences 11 0.000 I 10 1.704' S Need ior faculty to he nre directly involved in clinical practice to enhance their understanding oi iwlications of health care econaics 12 0.761 N 13 1.304' S on quality oi nursing care lore si-Ilated clinical activities are used It the in-patient hospital length-oi-atay and population decreased 13 0.601 N 15 1.239' s Alteration in clinical requir-enta; that is. abbreviated nursing care plans 14 0.639 I 14 1.271' S Enhaaia on the develop-ht oi critical nursing stills ior patient care in «unity settings (ventilator care. chmtherapy ahinistration. etc.) 15 0.623 u 11 1.377‘ S Iecesaitated changes in clinical hours 16 0.458 I 16 1.129' s Increased the Inner oi consecutive days oi continuous ti. in c-anity health settings 17 0.446 Ii 17 1.045‘ S Increased the Mr of consecutive days of continuoue tile ih long- terI care aettinps 10 0.2l2 I 10 0.057' s Increased the Inner oi consecutive days oi continuous H. in acut care settings ' 19 0.271 I 19 0.630' ii &. Interpretive codea for the rahpes ior lean Icores: Ii - lone lean oi 0.949 and below 5 - slight iIean oi 0.950 to 1.949 ii - lbderate lion oi 1.950 to 2.549 . $0 - Suoatantial Mean oi 2.550 and above 1' 7' 123 ' g < .01. too-tailed ~- oeunen recent and iuture "It! 12: aaccuauhws DEG!!! "MINI MS! EDRCMOIS' PEICEPTIONS 0F liit PRESENT AND FUTURE INFLUENCE OF MSPECTIVE ”WENT SVSTEHS (Dam) on aaccauuem: DEGREE MS!“ "WINS TIMI LED 70 INIIIAI. LICENSURE PRESENT mine: I 1 s n we: ran ' ms: rot: Mil MEAN scout nun SCORE mt HEM SCORE nun SCORE Increased mhasis on political] economic/legal issues in nursing . curriculum 1 LS]. S 2 2.203' N Increased enhasis on hole care/ cmnity clinical esperiences 2 1.405 5 3.5 2.109' M Increased enhasis on geriatric * clinical eeperiences 3 1.361 S 7 2.020' M Increased ewhhsis on snorting with clients and their fanilies as part or discharge planning a 1.351 S 1 2.270' n Increased collaboration with nursing service agencies to better prepare nurses in caring for patients with 5 1.297 S 6 2.054' N shorter length-of-stays Increased ewhasis on working uith other health care providers or agencies as part at discharge planning 6 1.278 S 5 2.167' N iiave instituted instruction (or . faculty and students to better prepare th- ior confronting ecoholic issues associated rich 7 1.2.3 5 0 2.027‘ M health care cost containment iiave instituted instruction for faculty and students to better prepare tn. 'or confronting ethical issues associated with 3 1.189 S 10 1.865' 5 health care cost contair-ent Ewhasis on the develop-ens of critical nursing skills for patient care in co-mity settings (ventilator - care. chenotherapy ad-inistration. etc.) 9 1.135 S 3.5 2.109' N Increased ewhasis on skills related to teaching clients 10 1.05l S 9 2.000' M Need for (aculty to he lore directly involved in clinical practice to enhance their understanding of inlications of health care econs-ics 11 0.9‘6 ii 12 1.5i1' S on duality of nursing care lecessitated changes in clinical placements 12 0.892 N 11 1.750' S Increased eeohasis on coeanmication stills 13 0.70! a 10 1.270' S Alteration in clinical requirunts; that is. abbreviated nursing care plans 1‘ 0.730 ii ‘ 13 1.324‘ S lore slaulated clinical activities are used as the in-patient hospital length-of-stay and population decreased 15 0.514 I 16 1.243' 5 iiecessitated changes in clinical hours 16.5 0.!05 N 15 1.257' S Increased the nmr of consecutive days of continuous tin in long- terI care settings 16.5 0.105 ll 1! _ 1.083’ S Increased the nuwer of consecutive " days of continuous tine in cmhity health settings 10 0.270 I 17 1.139' S Increased the muer 07 consecutive days of continuous tile in acute care settings 19 0.189 n 19 0.657' N M. Interpretive codes (or the ranges for mean scores: It - hone Mean of 0.9“ and below S - Slight Mean of 0.950 to 1.!” It - lbderate liean of 1.950 to 2.5“ . $0 I Substential Nean of 2.550 and above n - :7 124 ' l < .01. taro-tailed -- beteuen present and future Of all of thé items, the two for which there was a significant difference between ADN and BSN programs were: Increased emphasis on home care/community clinical experiences Emphasis on the development of critical nursing skills for patient care in community settings These are the same items for which significant differences were evident at the present time. As indicated above, these items were in the "moderate" range for BSN programs and in the ”slight" range for ADN programs. The following nine items, listed in rank order from the mean scores for ADN/BSN programs combined, were in the "slight" range for both ADN and BSN programs: Have instituted instruction for faculty and students to better prepare them for confronting ethical issues associated with health care cost containment Necessitated changes in clinical placements Need for faculty to be more directly involved in clinical practice to enhance their understanding of implications of health care economics on quality of nursing care Increased emphasis on communication skills Alteration in clinical requirements; that is, abbreviated nursing care plans More stimulated clinical activities are used as the in-patient hospital length-of-stay and population decreased Necessitated changes in clinical hours Increased the number of consecutive days of continuous time in community health settings 125 Increased the number of consecutive days of continuous time in long- term care settings The one item that remained in the ”none" range was: Increased the number of consecutive days of continuous time in acute care settings Comparison of AACN Results with WIN Results for BSN Programs Comparison of the results from the AACN study (AACN, 1986, p. 8) with the WIN results indicates that for all comparable items, the influence of DRGs on baccalaureate programs has dramatically increased from 1984 to the present and should continue to increase into the future (1992). In 1984, 76 percent of the AACN respondents indicated that DRGs had increased emphasis on home care/community clinical experiences; 89 percent of the WIN respondents indicated this emphasis for 1987. For 1992, 100 percent of the respondents indicated increased emphasis on home care/community clinical experiences. Increased emphasis on political/economic/legal issues in nursing curricula was identified by 59 percent of the AACN respondents. For the present, 89 percent of respondents indicated this need, and for the future, 97 percent. Increased collaboration with nursing service agencies was perceived by 42 percent of the AACN respondents. For 1987, 84 percent of the WIN respondents indicated increased collaboration, and for 1992 the percentage was up to 95 percent. Instruction for faculty and students to prepare them for 126 ethical/economic issues was indicated by 42 percent of the 1984 respondents. Instruction for ethical issues was indicated by 73 percent of the WIN respondents for the present, and 86 percent for 1992. Instruction for economic issues was indicated by 76 percent of the WIN respondents for the present and 89 percent for 1992. The emphasis on the development of critical nursing skills for patient care in community settings increased from 37 percent in 1984 to 78 percent at the present to 100 percent for 1992. The need for faculty to be more directly involved in clinical practice increased from 29 percent in 1984 to 65 percent at the present to 79 percent for 1992. Alteration in clinical requirements increased from 18 percent in 1984 to 54 percent at the present to 73 percent in 1992. Changes in clinical placements and/or clinical hours were noted by 54 percent of the respondents in 1984. Sixty-five percent of the WIN respondents indicated changes in clinical placements at the present and 89 percent for the future. Changes in clinical hours dropped to 32 percent at the present but increased to 77 percent for the future. The use of more simulated clinical activities increased from 12 percent in 1984 to 43 percent at the present to 78 percent for the future. Reference AACN Summary Report (1986). Generic Baccalaureate Nursing Data Project (1983-1986), American Association of Colleges of Nursing. 127 REPORT OF THE PANEL OF EXPERTS MEETING The panel of experts for the western region met November 10-] l, 1987, in Denver, Colorado. The following section includes a summary of the discussion regarding the impact of DRGs on nursing in institutional and community health settings and the implications for undergraduate nursing curricula. The section concludes with the recommendations made by the panel members. Impact of DRGs on Nursing in Institutions and Community Health Settings The implementation of prospective payment systems, such as diagnostic-related groups (DRGs), has brought about many changes in the health care delivery system, and these changes have implications for . nursing care. Changes in the Health Care Delivery System As a result of the prospective payment systems the length of stay in hospitals has decreased. Admission to hospitals frequently occurs just prior to surgery or diagnostic treatment procedures and patients are discharged earlier to the home or another facility. The patient population in hospitals now consists almost entirely of individuals who are acutely ill and who thus require a very high degree of sophisticated, complex nursing care. There is a shorter period of time to plan, implement and evaluate 128 nursing care. Individuals with higher acuity levels requiring complex care are now being discharged to long-term care facilities or to the home. As a result, the case mix in institutional and community settings has changed. Hospitals no longer have a mix of patients with varying degrees of acuity. In contrast, long-term care facilities and community health agencies now have an increasing number of acutely ill patients in addition to the client population served in the past. The increase in the number of persons in the older age group in the west is reflected in the patient population served in institutional and community health settings. A number of hospitals have expanded outpatient services to include ambulatory surgery and treatment centers, long-term care units, and home health care. Alternative settings such as hospices, respite care centers, surgicenters and walk-in ambulatory centers are now providing care. The broad array of providers of health care and the multiple care, settings increase the need for communication, coordination, and collaboration. The roles and responsibilities of each group of health care providers must be understood, and close linkages are needed to provide cost-effective care resulting in desired outcomes. Documentation has become increasingly important for continuity of care and for legal and reimbursement purposes. Payment for care may be denied if documentation is not perceived as adequate. Although such denials may later be reversed after reconsideration, the time needed to bring about the reversal can be extensive, and cash flow is affected. The change in reimbursement from a fee for service to a prospective 129 payment system has created changes in staffing patterns and in the amount of funds available for capital outlays for equipment and supplies. ‘Health care providers are faced with ethical issues arising from rationing of health care. Providing quality care with limited resources creates critical decision-making situations. Health care policies influence who receives care, what care is delivered and by whom, and who is reimbursed for what. Active involvement in the development of health care policies is essential to promote quality, accessible, cost-effective care and the appropriate work environment for professional functioning. Implications for Nursing Care Shifts in the locations of clients and care settings and changes in the types of care required increase the need for knowledgeable nurses who are flexible and adaptable. Nurses with specialized preparation in one or more areas and who are expert generalists are essential for the provision of quality care. To meet today’s needs, agencies are promoting continuing education programs, using consultants, or are contracting for services. For the future, the preparation of nurses may require post-baccalaureate education. The client population requires a staff complement prepared to provide highly complex quality nursing care. The intensity level creates problems in assignments for both new graduates and students and adds stresses for the nursing staff. 130 Patients are frequently admitted to hospitals just prior to surgery or diagnostic/treatment procedures and are discharged within a very shortened period of time. Nurses must assess what patient teaching was done prior to hospitalization and determine what needs to be done during the short stay. The high acuity level of the patient and the short span of time available for nursing care require rapid decision making. Unless appropriate care is planned, implemented, and coordinated, patients and family are not adequately prepared for care in the home or other facilities. Because of the short, intense hospital stay, nurses on patient care units do not have the satisfaction of seeing patients through the recovery phase or of seeing the results of some nursing interventions. As one means of promoting continuity of care for patients and more prolonged interactions with patients, some agencies have instituted a plan whereby a unit-based nurse does follow-up care in the home. Nurses working in hospital-based outpatient services such as ambulatory care centers and treatment centers are caring for the less acutely ill but have even less time to provide care to these individuals and their families. Nurses working in long-term care facilities and community health agencies are now expected to provide the type of care previously provided in acute-care facilities. They thus need the appropriate knowledge and skills to provide acute care. Nurses employed to provide care in hospital-based home health care services and long-term care units need the appropriate knowledge and skills to provide community-based care and to meet the nursing requirements of long-term care patients. 131 Staffing patterns are changing. With decreases in staffing in departments such as physical therapy, occupational therapy, respiratory therapy, and dietary, nurses are increasingly taking over these important components ‘of care. As other services, such as clerical and housekeeping, are decreased, nurses are directly or indirectly expected to take on more non-nurse activities. Although the ratio of registered nurses to patients may be increasing in some facilities, the number of assistants to nurses is decreasing and the additional activities being taken on by nurses may create stresses and frustrations for the caregivers. Clinical specialists provide support for staff by serving as consultants and role models in institutional and community settings. Well-prepared nurses can provide the clinical expertise needed and assist others in coping with the stressors in the work environment. Fluctuations in census create needs for more or less staff. At points of high census, insufficient numbers of nurses may be available. Nurses may then be expected to work overtime. Shifting of nurses between units with low census to high census may also occur. Such shifting of resources may create staffing patterns that do not consider the expertise of the nursing staff. At points of low census, some nurses may be placed on leave without pay, creating employment insecurity. Some home health agencies are implementing a pay structure based on productivity--that is, nurses are paid for visits made. Such an approach decreases use of temporary help but increases the nurse’s workload. When reimbursement for a visit is denied, the nurse may not be compensated for 132 that visit. Reimbursement of staff when nursing students make the home visits is another factor to be considered. ‘ A number of home health care agencies are providing nursing care 24 hours daily. As a result, nurses employed by such agencies no longer have the benefit of working the preferred shifts and days. Additionally, many agencies do not differentiate job descriptions and salaries amongigraduates with differing educational preparation. This has led to inappropriate utilization of nursing personnel and lack of recognition for educational preparations. The increasing demands, the uncertainties in employment, the lack of control over hours worked, the relatively low salaries, and a sense of devaluing of nurses have contributed to "burnout.” If more nurses seek improved work environments by changing places of employment in the health care system or even leave nursing, increases in turnover rates and in shortages will occur. Documentation for legal reimbursement purposes, and for communication with other health care professionals, has become a major activity of nurses. Approximately 50 percent of a nurse’s time in a home health agency is devoted to documentation. Nurses in institutional settings also spend a high percentage of time in documentation. Although documentation is essential, a more simplified cost effective way for providing the information is needed. Nurses must to be well prepared to document effectively. Knowledge about the financing of health care is becoming 133 increasingly important. Nurses must be aware of the cost of care and be cost conscious. The ability to ask the right questions is essential. Decisions need to be made regarding what is best for the patient and what is most cost effective. Nursing care should be appropriately reimbursed. For example, care provided to acutely ill patients in long-term care facilities should be reimbursed at a level consistent with that amount reimbursed to hospitals. The results of changes in reimbursement mechanisms, changes in staffing, and shortages of health care providers all contribute to the rationing of care. The ethical issues arising from such rationing must be addressed by nursing. Statements of philosophy of nursing care may need to be re-cxamined in light of who receives or does not receive care based on reimbursement mechanisms. Competition for clients and for nursing personnel is increasing. Marketing skills to increase consumer awareness of services provided and strategies to attract and retain nursing personnel are becoming more important. Nurses should be more actively involved in the political process and in determining health care policies if nursing is to impact the delivery and financing of care for all citizens. 134 Implications for Nursing Education Nursing programs need to make modifications to curricula that reflect the changes in the populations now served in various settings and the other significant changes in the health care delivery system resulting from DRGs. As indicated in the responses to the questionnaire and by panel members, some changes are occurring. Examples of change include but are not limited to the joint development of a course by nurses with expertise in community health and in geriatric care, the introduction of community health content in associate degree programs to assist students in under- standing that patient care extends beyond the hospital setting and the use of computer simulations to better prepare students for patient care. The substantial impact on and changes in .nursing practices reflected by the panelists and in the questionnaire results from health care agencies were not as evident in the responses of nurse educators who completed the questionnaire. Possible reasons for this difference include (1) changes made in the curricula are based on a number of factors, only one being the prospective payment system; (2) administrators may identify changes differently than faculty members; (3) changes in academia occur slowly; and (4) educators are not completely aware of the significant changes in the clinical settings and the health care delivery system. The role of the hospital as a major setting for student experiences needs to be re-examined in light of the acuity level of patients and the short hospital stay. Some hospitals or units within hospitals are not 135 appropriate for student experiences because the patients are too acutely ill and require such sophisticated care that they cannot be assigned to stu- dents. The short hospital stay decreases the opportunity f or students to see the "natural” progression of care and recovery, such as wound healing. Unless provisions are "made for students to follow patients from one setting to another, they do not gain the needed understandings associated with such importance of effective teaching and discharge planning. The participation of nurses from health-care agencies in the educational program of students has been increasing. A number of nurses serve as mentors or preceptors and on joint committees. In those agencies or units where there is a shortage of staff, the participation in and support by staff in the educational process for students becomes very limited. Clinical experiences for students may be altered if the census is low and staff are shifted to other units or are placed on leave. Some agencies may not be appropriate for educational experiences because of the critical shortage of prepared staff. Students need to be prepared for the realities of the work world. For example, students prepare extensive nursing care plans as a meaningful learning experience and evaluation tool. Such plans are not appropriate as nursing care plans in clinical settings. Students should learn how to develop and use effective plans consistent with agency plans. Types of knowledge, use of knowledge, and analytical reasoning skills are emphasized in educational programs. Greater emphasis needs to be placed on helping students learn how to use knowledge and the inductive 1‘36 process. One approach suggested was to have available generic nursing care plans which students adapt to individual situations. The changes in the marketplace demand that students be better prepared to provide critical care and long-term care. Increased emphasis on patient teaching, discharge planning, collaborating and communicating with others is also needed. Students also need to be well prepared in rapid decision making and ethical decision making. Means to increase the students’ understanding of the cost of care and health care financing is necessary. Including some cost factors in care plansis one way of accomplishing this goal. Concern was also expressed regarding who pays for students learning in clinical settings. Some agencies are charging schools for clinical experiences and are submitting bills to schools for costs related to students’ inefficiency in settings (e.g., cost of trays contaminated by students). More simulations are needed to provide students with the opportunity to think through experience situations, which are difficult to provide in actual clinical settings. Fiction could be developed to provide such experiences, as could more simulations for computer application. Laboratories need to be well equipped so students can practice without the potential of increasing costs due to such incidents as breaking or contaminating equipment. The cost of educating students and ways of financing education needs further study. Nursing education would benefit from pass-through monies 137 as medical education now does. Changes in curricula frequently take a great deal of time because of vested interests of faculty and the decision-making and approval process. The process of accreditation developed by nursing does not lead to innovation. Collaboration between faculty and service is needed in curricula revision. Recommendations The papers, presentations, and discussions served as the basis for recommendations for modifications in curricula. The panel identified a number of areas that needed to be further emphasized in nursing programs and changes in types of experiences and teaching strategies used in programs. Specifically, the panel recommended: - increased emphasis on changes in the health care delivery system, the populations served, and the financing and cost of health care - increased emphasis on communication skills, such as effective documentation and use of agency care plans - increased emphasis on patient teaching and discharge planning - increased emphasis on theoretical content and clinical experiences related to the care of the elderly - discussion of ethical dilemmas and ethical decision making - use of various teaching strategies to assist students learning-- examples include simulations and the development of nursing ‘ fiction, which could portray specific aspects Such as the image of nursing, examples of care management - implementation of clinical experiences that facilitate client follow- through care for students 138 In planning and implementing modifications, collaboration between nursing in education and practice settings is needed. Faculty need opportunities to gain new knowledge and skills. It is further recommended that nurses increasingly be a part of policymaking groups concerned with resources and formulation of regulations. The panel recognized that major changes in the health care system create the need for major changes in nursing curricula. The panel also expressed concerns that recommendations to increase theoretical knowledge and clinical experiences foster the concept of teaching too much in too little time and may result in inadequate learning. Unless revisions are made to delete or decrease emphasis in certain areas, it is unrealistic to expect that within the time constraints of degree programs, adequate time and resources are a‘vailable to add content and experiences. The need to more clearly delineate the expectations of graduates prior to making major modifications in curricula was identified. The panel therefore indicated that the recommendations listed above should be considered as modifications that can be made in the short term. To more effectively meet the challenges for the future, the panel made other recommendations, which were viewed as primary and long-term. These recommendations relate to curricula, differentiation of the products from education programs, financing education, and policymaking. Specifically, the panel recommended that nursing curricula be reconceptualized. Factors to be considered in reconceptualization include, but are not limited to: 139 - demographics, such as the increasing number of older persons - competencies required in various settings where care is provided - types of knowledge needed - analytical reasoning skills needed - cognitive levels of the student populations - need for rapid decision making and priority setting - improved communication skills, including documentation - economics of health care - ethical issues and ethical decision making - increasing interdisciplinary collaborative experiences - incorporation of richer clinical experiences and different teaching strategies The panel recognized that the competencies of graduates needed both now and in the future should be delineated within the context of the health care delivery system, the role of nursing in that system and the educational system. The panel recommended that further studies be done to differentiate the preparation and utilization of associate degree and baccalaureate degree graduates and that these results be used in reconceptualizing nursing curricula. The panel emphasized that collaboration between nursing'practice and education is essential in curricula planning, implementation, and evaluation. Adequate financing of nursing education is required to provide quality accessible nursing programs. The panel recommended that pass-through funds (as are now available for medical education) be made available for 140 nursing education. The panel members recognized and recommended that nurses be included as a part of policymaking groups concerned with resources and formulation of regulations. This recommendation was viewed as appropriate for both the short and long term. The panel further stated that: l. Reimbursement mechanisms for long-term care be increased to more adequately cover the costs of providing required care. Ways to assist staff cope with stresses and to survive in the system need to be studied and implemented. Studies be carried out on the cost of nursing education. The impact of DRGs on graduate programs be studied. Studies be commissioned that analyze information and make recommendations on such important areas as teaching strategies to meet needs of students and nurses in rural areas. Demonstration projects to measure outcomes of care be carried out. 141 APPENDIX A:'Llst of Participants Panel of Experts Chair Marylou McAthie Professor Department of Nursing Sonoma State University Rohnert Park, California Authors of Papers Dorothy Kleffel Director of Research and Education The Visiting Nurse Foundation, Inc. Los Angeles, California Carol A. Lindeman Dean _ School of Nursing The Oregon Health Sciences Univ. Portland, Oregon Malinda S. Mitchell Associate Hospital Director Director of Nursing Stanford University Hospital Stanford, California Participants Kathryn Crisler Director of Nursing Partners Home Health Lakewood, Colorado Barbara Ferriz Director Department of Nursing San Juan College Farmington, New Mexico Sr. Lucia Gamroth Acting Director Benedictine Institute for Long Term Care Mt. Angel, Oregon and Doctoral Student The Oregon Health Sciences Univ. Portland, Oregon Susan Hazelton Director of Health Sciences Santa Monica College Santa Monica, California Sue Huether Associate Professor College of Nursing University of Utah Salt Lake City, Utah Ruth Ludemann Associate Dean for Academic Programs College of Nursing Arizona State University Tempe, Arizona Frankie T. Manning Chief of Nursing Services Seattle Veterans Administration Medical Center Seattle, Washington Toma Nisbet Program Manager for Policy and Development Division of Health and Medical Services State of Wyoming Cheyenne, Wyoming Therese Sullivan Chairperson Departmentof Nursing Carroll College Helena, Montana 142 Division of Nursing Representative Mary S. Hill Project Officer Division of Nursing BHPr, HRSA Rockville, Maryland Western Institute of Nursing Staff Jeanne M. Kearns Executive Director Patricia F. Uris Program Coordinator A Western Project to Improve Training in Geriatric Nursing Jane Ellen Innes Administrative Secretary Guests Suzanne Dibble Nurse Researcher Stanford University Hospital Stanford, California Bernice Szukalla WIN Emeritus Evergreen, Colorado 143 APPENDIX B: Agenda INFORMATION CONCERNING THE IMPACT OF THE PROSPECTIVE PAYMENT SYSTEM (DRG'S) IN THE REIMBURSEMENT OF HOSPITALS, 0N CLINICAL NURSING CARE BOTH IN HOSPITAL AND COMMUNITY SETTINGS [RFP No. HRSA 87-336(P)CLO] AGENDA FOR THE PANEL OF EXPERTS MEETING Dates and Time: November 10, 1987, 1:30 - 5:30 p.m. November 11, 1987, 9:00 a.m. - 4:00 p.m. Location: Denver Airport Hilton Hotel 4411 Peoria Street Denver, CO 80236 (303)373-5730 TUESDAYI NOVEMBER 10 1:30 - 2:00 p.m Welcome and Introductions Marylou McAthie, Chair Background and Rationale for the Project Mary (Flo) Hill Overview of the Project Jeanne M. Kearns Impact of DRGs on Nursing Care and Implications for Undergraduate Nursing 2:00 - 3:00 p.m. Highlights from the Authored Papers The Impact of DRG's on Clinical Nursing Care in Hospital Settings Malinda Mitchell The Impact of DRG's in Nursing Care in Community Care Settings Dorothy Kleffel DRG's - Implications for Undergraduate Nursing Curricula Carol Lindeman 3:00 - 3:15 p.m. Break 3:15 - 4:00 p.m. Long Term Care Resource Requirements Before and After DRG's Sr. Lucia Gamroth 4:00 - §:30 p.m. Sharing of Identified Impacts of DRG's and Implications for Education All Panelists 144 INFORMATION CONCERNING THE IMPACT OF THE PROSPECTIVE PAYMENT SYSTEM (DRG'S) IN THE REIMBURSEMENT 0F HOSPITALS, ON CLINICAL NURSING CARE 30m IN HOSPITAL AND comunm SETTINGS [RFP No. HRSA 87-336(P)CLO] NEDNESDAY, NOVEMBER 11, 1987 9:00 - 10:00 a.m. 10:00-10:15 10:15 - 12:15 12:15 - 1:30 p.m. 1:30 - 2:30 2:30 2:45 2:45 3:15 3:15 3:45 3:45 4:00 Discussion of Questionnaire Resu1ts Jeanne Kearns Break Imp1ications and Recommendations for Education* Based on the Impact of DRGs on Institutiona1 Settings A11 Pane1ists Luncheon Imp1ications and Recommendations for Education Based on the Impact of DRGS on Community Settings A11 Pane1ists Break Estab1ish Priorities for the Recommendations A11 Pane1ists Recommendations for Other Studies A11 Pane1ists C10sing Remarks Mary1ou McAthie * In making recommendations for education,the pane1ists wi11 address genera1 recommendations for undergraduate programs and specific recommendations for associate degree and bacca1aureate degree programs. fiU.S.GOVERNMMPRINTNGOFFICE: l 9 9 $20 1-5 9 75 Z 5 9 5 145 u” LlBRAI‘; NOV 1 4 1983 um. aenxem mums ' ‘ \IIIIIIIIIIII CDDH'Q'IEHHE BHPr US. DEPARTMENT OF HEALTH 6 HUMAN SERVICES Public Heoith Service Health Resources and Services Administration Bureau of Heokh Professions