We live in a time of transition. Societal changes, specifically those triggered by fiscal constraints, are influencing the traditional system of healthcare delivery in the United States. Virtually all levels of healthcare providers are being forced to assess the degree of effectiveness and efficiency associated with their function within the system. For example, the traditional models of providing nursing care are being challenged to respond to the present needs of society.
Two specific changes are linked to the current demands on nursing. First, the changing nature of the age structure in the United States has increased the number of patients who are over the age of 65. Many of these patients claim at least one chronic illness.1 Second, the Medicare prospective payment system (PPS) has decreased the length of inpatient hospitalization days and released patients into the community who often require complex nursing care.
Problem Statement and Purpose
Nursing is forced to address the following questions:
1. Will traditional models of delivering nursing care to the frail elderly or persons over the age of 75 meet the present and future needs of society?
2. Should nursing models differ in the acute and home care settings?
3. If different nursing models are proposed in each setting, can a bridge be developed between the settings to ensure continuity of patient care?
These questions are posed by nurses at The Johns Hopkins Medical Institutions (JHMI) who deliver inpatient care to the frail elderly in the Department of Medicine and in the home care program known as the Post-Hospital Support Study. These departments communicate with each other as patients move between the acute care facility and the home setting.
This article focuses on the response of nursing to these demands by:
1 . Presenting an overview with potential outcomes of the societal changes associated with the prospective payment system;
2. Discussing the elderly population at JHMI in relationship to special nursing needs;
3. Reviewing the traditional nursing models of delivering care in the JHMI acute and home care practice settings and stating some of the nursing practice problems that have surfaced within these models; and
4. Proposing recommendations for planning changes in the nursing models that will assist nursing to meet present and future demands successfully.
Blum2 states that the major reason for planning is to obtain improvements in circumstances. Those who plan must understand the realities of the present. This includes the present and future age structure and the potential outcomes of the PPS.
Under the PPS, the federal government stipulates in advance how much it will pay for the treatment of a given episode of an illness. Basically, the new PPS classifies all patients in one of 470 diagnosis-related groups (DRG), with the exception of a small number of "outlier" patients. The hospital would receive a fixed payment per DRG regardless of treatment and length of stay. Those hospitals incurring lower costs than the fixed payment are allowed to keep the savings. The opposite is also true. Those hospitals spending more than allowed under the DRG would be required to absorb the costs.
The DRG program provides an incentive to manage hospital operations and deliver services to Medicare beneficiaries in a more efficient and costeffective manner. With the incentive to reduce the length of stay, more emphasis is being placed on outpatient services, preadmission testing, same-day surgery, and care after discharge. Those who criticize the system are concerned that patients formerly treated in outpatient departments may be admitted to inpatient services, and some patients, particularly the frail elderly, may be discharged prematurely.3
Under the PPS, changes in clinical practice will be necessary as a result of the reduced length of stay. There will be less time to develop and implement discharge plans. More stress will be placed on healthcare providers as patients are discharged with more complicated plans of care.4 There is growing consensus that early discharge planning is a requisite for survival under the PPS. Although most managers support discharge planning from the time of admission,5,6 some advocate discharge planning before the patient is admitted.4 Many are concerned about the adverse effects of PPS on patient care. There certainly will not be "as many frills or fringes as in the past."7
Although it is believed that this type of incentive program will decrease total healthcare costs, it is feared that the frail elderly population is at risk for compromised quality of care along with difficulty in accessing care. The reason for this fear is that hospitals stand to lose money by caring for those over the age of 70. The new prospective payment plan does not take into account that the average length of hospital stay increases with age, a factor that influences increased cost. In addition, the PPS does not recognize multiple clinical problems or severity of illness. Since the elderly often exhibit serious, multiple medical problems, hospital administrators may view the elderly as undesirable revenue losers. Hospital management could conceivably select against the high-cost elderly patient in favor of short-stay patients.8
Nursing administrators recently surveyed in New Jersey have evaluated some of the effects of PPS.5 The new system has forced a strong commitment on the part of hospital employees to provide effective and efficient patient care. The survey revealed that personnel emphasized the value of patient care planning, patient classification systems, and discharge planning. This would not have been true prior to the implementation of the PPS.
Changes were also noted in the clinical area. There was an increase in the nursing care hours per patient and in the number of aged patients admitted. Patients who could receive care in alternative community-based services were not admitted to the hospital. Those hospitalized patients for whom home health services could be arranged were discharged early. As a result, an increase in referrals to home health agencies was noted. Some patients were deemed by the agencies to be too ill for solely daytime coverage. Such cases are being considered for evening home care coverage.5
The Elderly Population at JHMI
Changes in the age structure of the patients admitted to the Department of Medicine have been noted over the past several years.9 In 1982 of the 7,504 patients admitted to the Department of Medicine, 30%, or 2,243 patients, were 65 years old or older. These individuals accounted for 35% of the total inpatient hospital days. In 1983 there was an increase in the number of patients 65 or older who were admitted for care; that is, 32% of all patients were over 65. This elderly population accounted for 36% of all patient days. These trends are projected to continue.
According to Metcalf, the nursing staff has identified special care needs in the aged cohort. Many of these individuals, for instance, suffer auditory and visual deficits that result in communication problems. As many as half of those treated are thought to be cogniti vely impaired. Discharge planning and follow-up care must be reflective of these serious impairments. Patient teaching and discharge planning can be extremely difficult goals to implement with patients who lack the abilities to speak, hear, and process information.
Discharge plans are also affected by patient health decrements such as unsteady gait and decreased mobility. These conditions are often exacerbated by complete bed rest during hospitalization. In such cases, the independent functional ability of the patient must be measured prior to discharge, and physical therapy is instituted for rehabilitation, as indicated.
Malnutrition is also a major health problem. Some of the factors that contribute to compromised nutritional states include the inability of patients to adhere to recommended diets, functional limitations, cognitive deficits, and lack of knowledge about proper nutrition.9
Patients and their families may need assistance with planning for home care of health and nutrition problems. Additional care problems include urinary and fecal incontinence. Those with compromised nutritional states may require tube feedings. Patients may become depressed as a result of physical insult and environmental factors. These factors include the loss of independence that occurs with hospitalization, loss of familiar surroundings, and social isolation. Depression can impede immediate recovery and compromise the potential gains that contribute to successful recuperation over time. In summary, Metcalf has proposed that the frail elderly experience physical decrements that require increased nursing contact hours and complex discharge planning.
Nursing Practice at JHMI
Primary nursing is the model of delivering comprehensive nursing care within the Department of Medicine. Autonomy, accountability, advocacy, collaboration, coordination, and communication are among the key elements needed to operational ize the concept of primary nursing.10 The primary nurse is the nursing representative to the patient during his or her contact with the hospital. The primary nurse plans for total patient care from admission to discharge for a select group of patients and their families.
The patient is the central focus for planning, implementing, and evaluating care. Aspects of the individual's physical, emotional, spiritual, and social well-being are considered. The primary nurse assumes 24-hour accountability for the patient care being delivered. He or she collaborates and communicates with other members of the Healthcare team about the status of the patient and the plan of care. As the patient's advocate, the nurse addresses problems that the patient or the patient's family are experiencing within the healthcare system.10
The primary nurse begins discharge planning at the time of the patient's admission. The care of all patients is reviewed weekly at interdisciplinary rounds, which are attended by nurses, physicians, social workers, a pharmacist, occupational therapists, and physical therapists. A liaison nurse or social worker from home care services, such as the Post-Hospital Support Study, often attends rounds and accepts patients who would benefit from home services.
As a means of preparing registered nurses for the role of primary nurse, a variety of workshops are offered. These educational programs include content on the roles of charge nurse and primary nurse, methods of patient education, and theory on adult learning. Within this framework nurses leam principles of assertiveness and patient advocacy.
The frail elderly home care project known as the Post-Hospital Support Study delivers nursing care through the case management model. According to Bell,11 this form of community or public health nursing cuts across professional boundaries and is responsible for identifying, securing, and coordinating all the resources necessary for the patient's life in the community. Direct physical care is delivered by the nurse case manager. After an assessment process, the manager is responsible for providing a 24-hour plan that coordinates the activities and services of those involved, which includes the quality of service and the patient response to the plan. The case manager also functions as an advocate, intervening on the patient's behalf when necessary.
Wiles12 addresses collaboration as an integral part of home care nursing. Without effective collaboration there would be no continuity of care provided and the client's understanding of the home care program would be fragmented. Each client has an individualized care plan even though the client may have problems similar to others in a specific disease category classification. Wiles states that in home care, interdisciplinary services are documented. This requirement allows for accountability of each professional and fosters continuity of care. Wiles explains that in home care, as in other healthcare settings, professionals experience stress associated with changing roles and overlapping boundaries. In collaborating, health providers in the home should carefully analyze one another's roles to determine if overlapping occurs.
In addition to the communication skills required in the collaborative process, the case manager assumes broadly focused responsibilities. Arbeiter13 states that the community or public health nurse must put a premium on self-reliance, flexibility, adaptability, confidence, versatility, knowledge of systems, cooperation, and teaching. The author summarizes, "You have to learn to play the hand you're dealt. " To do this, Wiles recommends that the case manager understand:
1 . Application of the group process to achieve group goals;
2. Problem-solving process;
3. Role theory;
4. What other professionals do and how they see their roles; and
5. The conceptual differences between home care, practice, and institutional care practices.
In comparing the case manager role and the role of primary nurse, Bell11 determines that both have accountability and responsibility for a 24-hour plan of care that includes implementation and evaluation. The roles are also similar in that it is easier for the patient to organize requests for assistance around one person, rather than negotiate individual requests with a variety of persons. In contrast with the primary nursing role, Bell states that the case manager role is also concerned with the development of a social network, which is an area of responsibility typically associated with the social worker. A nurse fulfilling this function can enlarge the scope of the 24-hour plan to include interventions that meet nursing and healthcare needs as well.
Nursing Practice Problems
In the acute care setting, the following problems have surfaced. First, there is an increasing sense of frustration experienced by the nurse in implementing complex care plans for the frail elderly. A significant number of patients in this population bear the potential for serious, multisystem physical problems. The related care plans and patient teaching needs are commensurately complex and labor-intensive. Often, as a result of the reduction in the length of stay, there is not enough time to carry out the plan of care or to meet the individual's teaching and learning needs. Therefore, planning must begin at admission and be continued after discharge. The present system does not allow for a smooth transition of the plan of care for the frail elderly from the hospital to the home.
Second, although gerontology has developed as a major science during the 20th century, knowledge about the care of the elderly is still missing in the academic and healthcare practice settings. Reflective of this deficit, the nurse is not educationally prepared to meet the special care needs of the frail elderly. Knowledge of the aging process and the potential iatrogenic consequences of medical therapies is lacking. No formal continuing education program is offered to or required of the nurse who cares for such a large , chronically ill population. Educational programs with content specific to agerelated health changes, communication styles, and teaching-learning skills are essential. Nurses could then design complex plans of care. An important step in filling these educational needs has been taken. Several staff members within the department have developed written standards for delivering care to elderly patients.
In the course of developing the role of the nurse case manager in the home setting, problems in delivery of service to the frail elderly have also been identified. The profile of problems is as follows.
First, the home care nurse is seldom given adequate information by the acute care nurse to ensure that the care plan is immediately modified for the home setting. This lack of coordination makes for duplication of efforts and lost time, and negates the position of advocacy that the acute care nurse assumed on behalf of the patient. The home care nurse often faces a set of home needs that require immediate attention and are overwhelming for a single nurse.
Second, the home care nurse is inexperienced in the practice of community health nursing as previously defined by Bell. No formal continuing education plan has been designed to assist the nurse in gaining the necessary knowledge and skills. Some informal teaching has been conducted by the program director, who is an adult nurse practitioner, and the psychogeriatric nurse consultant, who is a community health specialist. These teaching sessions have occurred when the home care nurse has identified barriers to the delivery of care that are associated with inexperience or lack of knowledge.
Third, the home care nurse is assigned a patient and family to follow in tandem with a social worker, who is educated to assume the responsibilities of case management. The outcome is a shared form of case management with blurred lines of responsibility and accountability. Without guidelines or clear expectations, role ambiguity and role conflict have developed. The indistinct division of roles has been a source of major stress for both members of the care giving dyad.
The literature on planning for Healthcare delivery in the 1980s addresses such problems. Blum2 states that the problems themselves are sources of never-ending pressure for improvement. An awareness of possibilities for improvement come from several directions. The author explains that pressures for planning come particularly from our never-ending desire to create a better future, the distress created by current problems, and our increasing awareness that we need a new kind of understanding to rationalize our actions. Blum believes that as problems recur they become recognizable and .involve more and more persons; problems then take on sizeable dimensions as forces for change. These remarks on the impetus for change apply to the delivery of nursing care to the frail elderly. As predicted, societal changes are influencing the current models of acute and home care nursing at JHMI.
Nursing Model Recommendations
The Post-Hospital Support Study may be viewed as a "project organization" that is operating within the functional, hierarchical structure of JHMI.14 This combination is known as a "matrix organization." Cleland and King15 claim that one of the advantages of a matrix organization is a better balance among time, cost, and performance. This balance occurs through a system of built-in checks and balances that are based on deliberate conflict and continuous negotiations between the project and functional organization.
In this open system, conflict is necessary to promote dynamic activity and growth. The statement on nursing practice problems can be interpreted as the necessary conflict that will promote developmental change within the matrix system. Two problems that have been empirically identified are the areas of unmet professional education needs and barriers to communication. The following recommendations are designed to alleviate these problems.
Education - Blum and Stein16 advise that the first task of planning is to conduct a needs assessment. Support is required by the nurse managers in the acute and home care settings. Recognizing educational deficits, the management of inpatient nursing has set up a program to meet educational needs. For example, workshops are offered on the concepts associated with primary nursing. Nurses involved in case management might similarly be offered instruction specific to that portion of the delivery system. Content might include theory on case management, families, values, and change; communication with the multidisciplinary team in the community setting; and means of accessing community resources and services.
Development of an educational bridge is, recommended to link both nursing groups in a shared workshop on the special care needs of the frail elderly. In response to the group needs in gerontological nursing, the content of the bridged program might include topics such. as age-related physical and normative psychosocial changes, cognitive impairment, drug toxicities, advanced assessment skills, communication with the elderly, and rehabilitation concepts. In effect, this educational package could be designed to assist the nursing staff in meeting the requisites- of the American Nurses' Association certification exams.
Nursing management can draw on the pool of experienced practitioners who are formally educated to deliver an advanced level of care within the hospital system. Costs can be contained by enlisting the aid of this network of available resources on a time-limited, brief basis. Library reference material should be updated so that the staff can review the literature as an expected step in solving complex practice problems. There are many creative, cost-effective educational possibilities.
Communication - As the educational bridge raises the group consciousness, communication between the nurses in the two segments of the delivery system is likely to develop. The bridge demonstrates that each group acts as an advocate for the patient within a network. Communications between interdisciplinary team members is likely to expand as nursing clarifies its practice position through an increased knowledge base and greater degree of accountability. Members of the team must learn to plan together and to recognize that blurred lines of involvement do not necessarily lead to a territorial dispute. The patient benefits if the team members join forces.
Management must be willing to give direction in assisting the providers in clarifying overlapping roles throughout the system. As an example of positive management intervention, the director of social work at JHMI offers supervisory assistance to the social work providers in both settings. Similarly, the director of the Post-Hospital Support Study assists the nursing and social work staff to increase communication skills and establish caregiving priorities. The psychogeriatric clinical nurse specialist offers consultation and instruction to management and staff about communication skills, group facilitation, and patient-related problems. The staff reports that these measures to facilitate communication are helpful.
Documentation - With staff assistance, managers can develop an improved documentation format. After reaching agreement on the necessary data base, documentation can be formalized and applied to the acute and home care settings. For example, a standardized patient problem list and medication calendar could be developed to serve as a patient assessment and evaluation tool over time . The list leads to a nursing diagnosis that is applicable in both care settings. This means that two nurses could conduct a rapid patient assessment in the same objective manner. At the time of patient transfer in either direction within the system, the accompanying information would ensure immediate and continuing interventions.
Enhanced continuity of care is likely to occur if the patient were responsible for safeguarding a copy of this document and for presenting it to professional providers each time the system is accessed.
Military personnel, for instance, carry documentation of blood type, immunization history, and health records as they transfer from one duty station to another. Costs to redesign the existing data base and discharge planning forms would involve minimal staff time and printing expenses.
Research - There is a need to conduct descriptive research. Such investigation would establish the pathway for future research treatments based on an experimental design. Certainly, there is a growing need to explore the following research questions:
1. Is it possible to describe the relationship between age structure, prospective reimbursement, severity of illness, and traditional models of delivering nursing care?
2. Is there a measurable change in quality of care delivered to the frail elderly before and after the intervention of staff education?
3. Does the cost involved in changing models of care make a difference in patient outcome as potentially measured by patient readmission rate, compliance to the plan of care, and morbidity-mortality rates?
The purpose of this article has been to present an overview of the potential relationship between the growing number of elderly patients with special healthcare needs and the traditional models of delivering nursing care. Nursing problems are barriers to communication and deficits in professional education.
Such problems provide an organization with the impetus to change and provide a more efficient and effective healthcare delivery system. Recommendations address the role that management might take to investigate these observations and to facilitate communication and the education process. Costs can be contained through use within the matrix organization.
Growth-promoting change can be the outcome of the questions that force nursing to address the problems faced in daily practice.
This is a time of transition for healthcare delivery systems. The role of nursing is an integral one in contributing to the advances that organizations are likely to make in the care of the frail elderly.
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