| How
did you get into nursing? Home health nursing?
My brother and I were a year apart in age. He was ill
throughout most of his life with a liver-related disease
and lived to be 13. We spent those first 12 years going
back and forth to Columbia-Presbyterian Hospital. My
first [memory] of those nurses was that I wanted to
be just like them.
Home health was a baptism by fire at the Columbia-Presbyterian
nursing program. We took the subways in New York to
the downtown Lower East Side to teach the principles
of home health to new moms and their babies. Those were
the first tenements I had ever entered. We had to climb
many stairs to get to their apartments. I saw rats that
had literally chewed and nibbled at the babies’
faces where the mothers had left food on the infants’
faces.
I remember distinctly that rats were part of that environment.
I was horrified, but thrilled at the prospect of teaching
those mothers in their own environment. It was exciting
to actually get through to those mothers and see that
I could bring about change.
What do you do?
My title is vice president and director of marketing/case
management. This includes marketing for HHS and intake
case management of newly referred patients. We have
grown from one to seven branches recently with plans
to expand further.
There is a lot of competition in home health and we
focus on customer service, provided through our on-site
case management department. Patients are often bewildered
and frightened about going home. We find that physicians
and discharge planners appreciate the attention to their
patients that we provide.
From an intake/case management perspective, we accept
the home health patient into our agency 24 hours a day.
We do an initial evaluation before they are ready to
go home. The department is composed of RNs, medical
social workers, and others with discharge planning experience.
We gather all the information to help organize care
for each patient.
How has home health changed
recently and how have you been affected?
Medicare, before 2000, reimbursed on a paid-per-visit
scale. This, unfortunately, created an incentive to
increase the number of visits and some unscrupulous
agencies made the most of that system.
After 2000, the Centers for Medicare & Medicaid
Services introduced a prospective payment system similar
to the shift from fee-for-service to diagnosis-related
groups of the 1980s. Today, home health receives a fixed
lump sum determined by the severity of the patient’s
status. Basically, the new system requires lower utilization
with high efficiency.
Tell me about decreasing visits and getting better
outcomes.
Under the Medicare payment system, an agency is given
an incentive to achieve the desired outcomes, such as
being able to get around the house better or remembering
to take medications. We have to have a plan that produces
the best-known care techniques for patient diagnoses.
Alzheimer’s, for instance, has clinical guides
that ensure success regardless of the clinician’s
personal level of expertise with the patient. They are
going to have the best-practice techniques such as hanging
a picture of a bed on the bedroom door or a toilet on
the bathroom door. Wandering can be curtailed with a
big, red stop sign on the exterior of the door or putting
a shoebox over the doorknob.
Tell me about HIV and home health.
Our goal is to keep our HIV patients at home as opposed
to hospitalization. This is done by establishing a good
patient-nurse relationship and working with medication
compliance. Many of our patients are on medication cocktails
and taking 40 to 50 pills a day. They need a lot of
encouragement. We also keep close tabs on weight and
immune status, concentrating on prevention.
Most of our clients are referred from the county hospital.
Ryan White funding is available for those with AIDS
who do not qualify for Medicare or Medicaid.
What challenges are you facing?
As a nurse executive, I am faced daily with cost structures
that must accommodate reimbursements based on previous
years. In October 2002, CMS imposed another 15% cut
in home health reimbursement. We are always streamlining
care and making comprehensive clinical guides or care
pathways more important.
This work has a concentration on details as well as
customer service. We want the patients and their referring
medical professionals to be happy. It is difficult to
find medical clinicians well-versed in the discharge
planning process.
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