IMPACT OF DRG’S ON NURSING REPORT OF THE MID-ATIANTIC REGIONAL NURSING ASSOCIATION US. DEPARTMENT OF HEALTH 6 HUMAN SERVICES Public Health Service Health Resources and Services Administration 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; . 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 0 Monitoring developments affecting health facil- ities, especially those in rural areas. IMPACT OF DRG’S ON NURSING REPORT OF THE MID-ATLANTIC REGIONAL NURSING ASSOCIATION 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 7 1988 {it/Mgol/ FUEL This report was prepared under purchase order number HRSA 87—339(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. Project Director is Shirley H. Fondiller, RN, EdD. This document is for sale by the National Technical Information Service, 5285 Port Royal Road, Springfield, VA 22161. Accession number: HRP—O907180. Issued: July 1988. ii FOREWORD Cost containment efforts in the reimbursement of health facilities under! a. 8 8 the prospective payment system have contributed to changes in the ' responsibilities and role of the nurse providing clinical care to 33557} L. patients. However, accurate data have not been available to assess the X ' 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 (HEP-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. liott irector Division of Nursing 111 CONTENTS Page Introduction ............................................................... iii Issues and Recommendations ................................................. l PRESENTATIONS .............................................................. The Impact of DRGs on Nursing Care in Community Setting ................. 5 The Impact of DRGs on Clinical Nursing Care in Hospitals ................ 30 The Impact of DRGs on Basic Nursing Education and Curriculum ............ 5] Implications Appendix A ........................................................... ..... 70 Conference Participants 7l Conference Agenda 73 Appendix B ................................................................ 74 MARNA Bibliography ..................................................... ; 75 «may .40 INTRODUCT ION 'Ihrough furding awarded by the Division of Nursing, DHHS, the Mid-Atlantic kgional Nursing Association initiated a six-nonth project in June 1987 on the inpact of 01265 on nursing in the five MRNA jurisdictions - Delaware, New Jersey, New York, Penna/Mania, and Washington, D.C. The effort ained specifically to address the effect of the prospective payment system in the reinhirsatent of hospitals, on clinical nursing in both hospitals and camunity settings. An anticipated outoone was to show the inplications of the study findings on the curriculum in undergraduate education, including diploma, associate degree, and baccalaureate prograne. Another expectation was to develop reocmrendations that would foster change relevant to regional needs arising frcm the DECS. To expedite the project, an Invitational Conference was planned for the fall, at which time the participants would explore the study material and suggest strategies as well as innovative approaches for projecting a future focus for nursing education and practice in the MARNA region. In preparation for this event, diree prominent nurse scholars developed mmgraphs on the following topics: "The Impact of DRGs in Nursing Care in Carmmity Settings," by mrflyn D. Harris, bSN, RN, QIAA,executive director, Visiting Nurse Association of Eastern antgarery Ommty (PA) ; "'Ihe Impact of 01265 on Clinical Nursing Care in Hospital Settings," by Joyce E. Johnson, 1115c, RN, associate administrator, Nursing Affairs, r[he Washington Hospital Center (DC); and "'Ihe Impact of DIES on Basic Nursing Education and Curriculum implications," by Lucille A. Joel, EdD, RN, chairperson, Department of Adults and the Aged, Rutgers, The State University of New Jersey. Earlier in the project, questionnaires were sent regionwide to a representative sample of oumunity health agencies, hospitals and nursing homes, and educational institutions to obtain data relevant to the study's purpose. The responses emanating frcm the three surveys were shared with the nonograph authors to imorporate into their papers. At the Invitational Conference held on October 19 and 20, several nursing leaders representing the MARNA oommnity, convened to discuss vii the presentations. Franklin A. Shaffer, EdD, RN, deputy director, National league for Nursing, who has written extensively on the prospective paynent system, chaired the day and a half meeting. Out of the group's deliberations came sane telling perceptions of the pressing ismes facing the nursing profession. It is hoped that the recamendations proposed, calling for visionary yet pragnetic approaches, will establish a pattern of beginning curriculum refonn in undergraduate nursing education. December 1987 Shirley H. Ebndiller, EdD, RN Executive Director Mid-Atlantic Regional Nursing Association viii ISSUES AND RECOMMENDATIONS The Invitational Conference on the Impact of DRGs on Nursing brought together leaders in the MARNA region to discuss the effect of Prospective Payment Systems on schools of nursing, nursing practice institutions, and community health agencies. Three monographs relating to each of these settings formed the basis for exploration at the Conference. As part of the discussion, the following questions were introduced to provide future direction for curriculum reform in undergraduate nursing education: 1. What kinds of knowledge and skills are needed by faculty who teach in the various types of basic education programs. in view of the changes created by prospective payment systems? What kinds of regional models are proposed to expedite curricular changes in basic nursing education? In light of Lucille Joel's paper and observations, could some kind of models be developed initiating curricular change within an entry level master's degree program? Out of the examination evolved pertinent issues and recommendations that are summarized below. I. ISSUES IN COMMUNITY HEALTH NURSING SETTINGS General Agency Concerns 0 More acutely ill patients require home care, thus create increased need for services. Older and more acutely ill patients receive less home visits due to (l; denials (medical and technical), (2) no assurance of payment, and (3 lack of referrals from sources such as ambulatory or short procedure units. Higher burden is placed on families by expecting too much of them in the home - such as dealing with technology. Increased home care services are being proVided by medical centers doing their own referrals. Need exists for VNAs to work with hospitals and to tap into their resources. Absence of accountability is evident when decisions for home care services are made by a reviewer in a distant office rather than by the professional in the home. Providers show unwillingness to extend services beyond what is reimbursable. Intensification of agency's financial problems are created by Medicare denials or by delays in response to appeals. (How much free service can you provide?) Problem of documentation and its effect on productivity is due to time involved to meet government's written requirements. Growing complexity of home care requires well prepared practitioners. Agencies are recruiting from hosoital intensive care units. Student/Faculty Concerns Unwillingness exists of many agencies to accept student placements. Need is apparent for more patients appropriate for student learning experience. Experience beyond observation appears necessary to help students fit into larger environment and learn intricacies of reimbursement system. Agencies want decision-makers. More consideration by schools is indicated to compensate agencies for student placement. Agencies must deal with negativism of undergraduate student coming to community health setting for learning experience. There is need for practicing faculty to serve as role models as well as for nursing to find better ways of marketing community health nursing as an exciting career option. 11, ISSUES IN HOSPITAL SETTINGS Contribution of nursing in DRG climate represents its greatest challenge to hospital administration. Greater accountability of nurses means having people with knowledge. Re-unification of nursing practice and nursing education becomes more critical than ever with PPS. Retention of quality vis a vis financial cutbacks is a nursing mandate for creative modeling in the practice setting. Support for an all R.N. staff (as shown in MARNA survey) must encompass concepts of cost effectiveness, nurses' autonomy, and a clearer evaluation of nursing services. Identification of nursing as a revenue producing system (yet to be documented) must be pursued. Use of the advocacy role of nurses can be demonstrated by encouraging patients to appeal if they believe themselves to be unjustly discharged. (Example: utilization review—nurse) III. ISSUES IN BASIC NURSING EDUCATION General Concerns Educational institutions in the MARNA region have not kept pace in their nursing curricula with changes created in practice by DRGs. Present health care scene is characterized by shrinking hospitals. eroding home care, deteriorating long term care, and nursing's desertion of community and ambulatory care. -An intimate relationship must be pursued between nurses in education and I practice. Educators have been less accountable in the service area. Faculty practice must be encouraged. Minimal attempt has been made to develop nursing faculty and assist them to beag_courant with the demands of the marketplace. Educators need to be more sensitive to trends in patient care needs. Student Concerns Since socialization is the most important goal of education, an intense study of nursing should be based on a pre-professional course of liberal arts and sciences. Consideration should be given to developing a health science core curriculum and clinical laboratory experiences that will bring together students from a variety of disciplines. Nursing curricula must encompass psychosocial and interactive skills that prepare for case coordination and service integration. The program should be designed to incorporate a sense of personal accountability. Student learning should be enhanced through courses of study that are selective, conceptual, and process oriented. Fresh approaches to teaching can be facilitated through use of the case method, simulation of clinical management, and computer-assisted instruction. A systems orientation is suggested in the curriculum to stimulate risk taking among students and to encourage intrapreneurship potential in the practice setting. Easing of the transition period from student to professional requires creative approaches, as well as work-study programs, summer placement, part-time work, and externships. Recruitment programs need re-examination so as to incorporate new ways of attracting the challenging student with risk-taking ability. RECOMMENDATIONS #l #2 As a result of DRGs, conference participants identified several areas of need to be considered for curriculum change in nursing. They reconnended the following concepts to be incorporated into the basic course of study: Management skills Human Resource Development Interdisciplinary Education and Practice Education Counseling and Peer Review Socialization High Tech/High Touch Ethics and Values Clarification Computer Literacy Research and Data Decision-Making Programs to expedite curricular reform should center around current models of excellence in education. Recommended was the development of a model curriculum 3 #3 #4 #5 at the master's level for entry into practice that would encompass the knowledge and skills delineated in Recommendation #1. Also suggested was the development of a model curriculum at the associate degree level. Recommended were practice and education demonstration models with extern/ internship programs for selection of clinical work and study experiences. Focus groups from the practice/educational sectors needed to be identified who would be committed to collaborative models. Fresh strategies should be implemented to make faculty more comfortable and clinically competent in practice. Recommended were potential workshops as one mechanism for assisting faculty in retooling for the curriculum changes needed,and in developing innovative programs. Recommended was that funding be sought for educational program development and demonstration projects. Also cited was the need for traineeships for shortage areas. THE IMPACT OF DRGS 0N NURSING CARE IN COMMUNITY SETTINGS Marilyn D. Harris, M.S.N., R.N., C.N.A.A. Executive Director Visiting Nurse Association of Eastern Montgomery County Abinqton. Pennsylvania The impact of Diagonosis Rleated Groups on community(home) health nursing must be viewed in light of corresponding developments that occurred at approximately the same time in home care. These included an overall financial cutback by the federal government through lower payment levels and more restrictive interpretation of the existing regulations by the Medicare fiscal intermediatries(FI) and private insurers. Soon after the effects of DRGs were beginning to be experienced, such as patients admitted to service requiring more acute level of care, agencies also began to undergo an increase in Medicare medical and technical denials. The Senate Special Committee on Aging (l985) noted that subsequent to the implementation of the Medicare Prosnective Payment System(PPS) in l983, hospital discharges to home health increased by 37 percent(lO/l/83-3/31/85). During the same period. the rate of growth in home health services slowed. Medicare-covered visits rose an average of l9 percent from l980-l983 but only 8 percent in l984, after PPS was initiated. The Committee further noted that a University of Virginia Nursing School survey, which compared patients referred to home health agencies before and after implementation of PPS, showed a 27.5 percent increase in the intensity of home health services reguired.(p.3) The fact that home care patients are more acutely ill can be documented in several ways. To begin with, a quick glance through an agency's policy and procedure manual will confirm the development and approval of many new high~technology(hi-tech) policies and procedures since 1983. Another way is by carrying out formal research.' At the Visiting Nurse Association of Eastern Montgomery County(VNA-EMC), we studies the medication usage in the homebound elderly for all patients admitted from February through April l985. Two 'hundred and ten clients over age 65 met the criteria for the study. The mean age was 76 years, with the mean number of Medicare diagnoses, 3.47; prescrip- tion medications, 4.8; and non—prescription medications, .94.(Lavizzo-Mourey et al, l987) ‘ A third way is to document the number of admissions and readmissions of the same patients to home care services. In our experience at the VNA- EMC, we have found an increased number of re-admissions with a shorter length of stay(now 28 days}. and with a decreased number of total visits(currently 13 per patient). The Denial Dilemma Home health care denials have nearly tripled since the last quarter of 1983 when PPS was introduced. There were 18,121 claims 'denied from October 1983 to December 1983; and 47,855 denials during the quarter January 1986 to March 1986.(Senate Committee, 1986) Data from the Health Care Financing Administration(HCFA) also indicated an increase in denials to home health agencies since 1983. From 1979 to 1982 the annual denial rates actually decreased from 1.9 percent of claims processed in 1979 to 1.5 percent three years later. There has been a 133 percent increase in the rate of denials from the last quarter of 1983 to the first quarter of 1986. From October 1983 to December 1983, the rate was 1.5 percent. An increase to 3.5 percent occurred from January 1986 to March 1986.(Senate Committee, 1986, p.3) In Pennsylvania. 2,332 Medicare beneficiaries in 75 agencies were denied health care coverage by the F1 in the eight months between September 1985 and April 1986. This figure represented a 2.5 percent rate for a total of 13,741 visitst During the period of January 1, 1987 through June 30. 1987, a total of 8.430 beneficiaries were denied service in 98 agencies. These denials represented a 6.5 percent rate for a total of 72,699 visits.(Pennsy1- vania Association of Home Health Agencies - PAHHA, ;987) The appeals process. including requests for reopenings, reconsiderations, and/or Administrative Law Judge(ALJ) hearings. has become time consuming and costly to the home health agency, but it is necessary in 1987. Reasons for the appeals include the beneficiaries' need for skilled care, home health care administrators‘ commitment to quality care for patients, and the agencies' need for financial solvency. The institute for Health and Aging at the University of California in San Francisco reported the results of data collected in a 1984 survey of 82 home health agencies. The findings showed that agencies faced problems resulting from HCFA's restrictive policies and the time required to document and appeal claims. The problems have led to the provider‘s unwillingness to extend service beyond what is certain to be reimbursed. In some cases. this practice goes against what might be medically preferable for the patient and may result in the lack of appropriate care for him. In this indirect way, cost containment has taken precedence over concern for proper care.(Senate Committee, 1986, p.5) Concern has been expressed by some home health administrators that in many instances home health agencies may be contributing to the notion of less need for home care services because of the decreasing number of visits. The other side of coin is that there has been over-utilization in the past. The National Association for Home Care(NAHC, 1986) reported that in one study of 39 home health agencies, the following was suggested: . .that some 30% of the patients receiving care under Medicare fell outside the home care box, that is they were either too sick, not sick enough, or not homebound, or in the judgment of HHS officials, the care ordered by physicians and given by home health agencies was not reasonable and necessary. For example, if agencies are experiencing an increased denial rate for selected disciplines or medical diagnoses, they may voluntarily limit the number of visits rather than provide needed service. Staff may also be discharging patients sooner and encouraging under-utilization of service. State Reports Data supplied by the four states(N.Y., N.J.. PA..DE.) and the District of Columbia, which comprise the Mid-Atlantic Regional Nursing Association (MARNA), revealed the information below. The years cited for available data were not always consistent. Marietta Taylor(Personal Correspondence, l987), health analyst for the Home Health Agency Assembly of New Jersey, shared the following information: I am sorry to report that since 1984, home health utilization in New Jersey has stagnated, largely due, in our view, to HCFA cost containment policies, particularly in the form of Medicare Claim denials . . .It’s a complicated scene. In addition to the chilling effect of claim denials, hospitals in New Jersey also have modified their admission policies in ways that negatively affect home health admission. In recent years, overnight admissions have declined whole use of same-day and out-patient clinics have increased. Unfortunately, patients treated in same- day or out-patient settings do not get tracked for discharge planning and referral to home care as carefully as those who are admitted to hospitals. In summary, the early evidence of increased home health utilization, associated with the implemen- tation of the DRG System in N.J., has been countered by federal cost-containment policies and changes in hospital admission practices. This co«mingling of trends makes forecasting very difficult. Clearly, reimbursement policies are enormously important. Highlights of the New Jersey Report 1985(N.J. Annual Report} For the second straight year in New Jersey, admissions to home health agencies declined in 1985. Since 1983, admissions decreased approximately a thousand persons per year. The elderly account for 71 percent of all patients and 77 percent of all visits in home health agencies. Home health utilization of the eldest-old(85 plus) has not increased in absolute numbers of that age group. Pennsylvania The latest published information on home health utilization from the PAHHA is the 1986 survey, in which 81 agencies participated. The over 65 age group account for 82.1 percent of all the population, with 36 percent between 75 and 84 years, and 14.9 percent over 85 years. The average number of visits per unduplicated patient was 25; the average length of stay, 64 days. Overall business has declined. According to Mary Kay Perra, executive director, PAHHA, agencies report an overall decrease of 23 percent in total visits as of July 1987. The VNA-EMC, a PAHHA member, has experienced a 25 percent decrease over the last fiscal year. A further decrease has been evident during the first quarter of the current fiscal year. Personal conversations with other directors have confirmed that total visists continue to decline as of September 1987. New-York Information provided by Timothy Burgers(Persona1 Correspondence, 1987), eudcation and information associate, Home Care Association. New York State, Inc., was as follows: Herbert Hooven,executive director of HCA, has asked me to respond to your request for information about the effects of DRGs on home care provision. While it is generally acknowledged by provider agencies that many clients require more intensive and frequent service as a result of earlier hospital discharge prompted by DRGs, the evidence is largely anecdotal. We do not have specific data readily available to document that effect. I have heard recently from home care agency administrators who were requested to provide services to clients that the administrators felt were not ready for discharge from the hospital, but to blame DRGs for these incidents may be inaccurate. Recent cutbacks in Medicare coverage of home care services have compounded the effects of DRGs. While hospitals are sending patients home sicker, Medicare is denying them the more intensive care they need. If DRGs are to succeed at cutting health care costs without neglecting the continuing health care needs of patients after they leave the hospital, Medicare coverage of home care services must be expanded. The NAHC Report(l987) included information on an annual report prepared by the New York State Council on Home Care Services and programs in New York. It noted the following on the future of home care in New York: Home-care will experience even greater growth, and with increasing speed. . . .A number of forces already at work in the current upsurge will continue and intensify. A key factor is that state policy lies firmly in the direction of home care. Another major influence was mentioned in the report: . .the fact that nationwide the healthcare system continues to change at an unprecedented pace, with clear "fall-out" for home care. Specific factors related to the future demand for home care services include the "graying" of America; the increased demand for long-term care services in general; the increase 'in Alzheimer's and AIDS patients; and advances in medical technology that greatly expand the capability for caring for the seriously ill in their own homes. Joan Caserta(Personal Communication, 1987), director, Nestchester Jewish Community Services in New York State, cited several issues that compound the effects of DRGs. Included were: a personnel shortage especially at the home health aide level; recent release of a moratorium on nursing home beds; more restrictive interpretations by their new fiscal intermediary; and a change in the Office of Aging Contract. Delawagg__ Donna Maraldo (Personal Communication, l987), director of health services, VNA of Delaware, provided information on the status of home 10 care as of this past September. She stated that three issues influence home care. One is the need for nurses with hi-tech skills to meet patient needs, which means hiring staff with special skills, or retraining present , staff - and that may require more time and dollars. Another issue is the increased competition. Prior to DRGs. there were two home health agencies; the number increased to 15 at its peak, with the present number at l3agencies. The third issue is the increased documentation requirement. Although no specific denial rates were available, Ms. Maraldo noted that her agency had experienced no denials until September 1985 when the new HCFA forms were initiated. District of Columbia Ruby Vancroft(1987) provided information on September 14. Assistant director for contracts and grants at the VNA of 0.0.. Ms. Vancroft indicated that her staff has found the present caseload to include sicker patients as evidenced by the need for two or three visits a day, intravenous therapy, and the need for more community resources. She also pointed to an increased number of patients with cancer. Increased documentation requirements have been addressed by having specific individuals responsible for the new JCFA forms so that visiting staff can maintain productivity standards.(5.4 visits per day) This has increased the cost of service. There has not been a significant increase in denials. An increase in the re-admission rate has occurred. (Selected data for MARNA jurisdictions appear on the following pages in Tables l and 2.) External Factors Affecting Home Care Services Several other external factors influence home health services and cempound the effects of DRGs. (a) W5 The 1980 U. S. Census Data indicate that the over 65 age group is the fastest growing section of the population. In 1985, 11 percent of the popula- tion was over 65 years , and this number will increase 20 percent by the year 2020. Within the over 65 age group, persons 80 years.and older represent the fastest growing number(2.7 percent in 1987' to 4.3 percent in 2020). 11 TABLE 1 Total Number of Medicare Visits in the United States and by the Five Jurisdictions in MARNA Region Year (Visits in Thousands) Area LL62: 218: 98;" Delaware 39 52 201 District of 30 56 93 Columbia New Jersey 471 976 1,651 New York 844 1,488 2,852 Pennsylvania 554 1,532 4,031 TOTAL UNITED STATES 8,535 17.070 39.863 3Data from Home Health Line - Decade Report. 1980. Karen Rak, Editor and Publisher. Vashington, D.C., p. 15. bData from H.C.F.A. 1984. Medicare Home Health Agency Services: Persons served, units, charges and reimbursements, by census region and state within Division. 12 SI TABLE 2: PERSONS SERVED, TOTAL VISITS AND VISITS PER PERSON -—"——’ IN MARNA AREA RESIDENCE PERSONS SERVED IN THOUSANDS TOTAL VISITS IN THOUSANDS VISITS PER PERSON 1983 1984 1983 1984 1983 1984 DELAWARE 4 5 147 201 36.5 40.3 DISTRICT OF 4 4 101 93 24.9 21.8 COLUMBIA NEW JERSEY 54 58 1.633 1.651 30.0 28.4 NEW YORK 107 112 2.670 2.852 24.9 25.5 PENNSYLVANIA 122 135 3.337 4.031 27.4 29.9 cHCFA Medicare Home Health Agency Services: Persons Served. Visits. Charges and Reimbursements by Census Region and State within District. 1983 & 1984. This aging population presents several challenges to home health administrators and staff. In many cases, the care-giving spouse is as old or older than the patient. Also, the spouse may be ill andiir'ieed 0f nursing care. "Old" children are sometimes taking care of “older" parents. In Case Study 1(Exhibit A), we see the frustration and anger experienced by one home health nurse who sought to provide needed services to an older patient - terminally ill - and to his wife. Many details of this nurse's story are not included in this narrative, which describes the impact of the denial dilemma and demographics in home care. (b) Changes in the Nuclear Family Changes in the nuclear family affect community health nursing services, particularly since more single parent households have increased. In l980. 6.77 percent of all households in the United States were female—headed with children under the age of 18. Also, in many familes where both adult members are employed, fewer caregivers are available throughout the day and night. Thus, a need exists for extended support services in skilled care and companion services. For families willing to pay for extended coverage, however, there are limited numbers of individuals to provide the services at any price in some areas. Patients and families commonly believe that since they have Medicare or other supplemental coverage, health care services will be paid for an indef- inite period of time. They are not aware of the numerous regulations, restrictions, and recent interpretations associated with their insurance coverage. Most recently, such nursing procedures as diabetic teaching or other follow-up procedures, have been denied with the statement: "The 7 patient should have been taught in the hospital." If family members are available, they may not be willing to learn specific procedures or to take the responsibility for them. Furthermore, many families depend on income from both adult members in order to meet the daily bills, not just the niceties of life. Yet, if one member remains at home, there may be decreased income - which leads to added stress on the family. Data from the American Association of Retired Persons Caregivers in Workplace Program indicate that family members provide 80 percent of the care needed by older relatives in 1987. It has also been observed that 14 employees faced with stressful personal problems. such as caregiving. will cost employers money through increased absenteeism and distraction on the job; and higher error rates and less productivity occur. It is suspected that caregivers use medical benefits to a greater degree than other employees. (c) Expanded Need for In-Home Services Although DRGs are usually thoughtof in the context of the Medicare Program, other third-party payors are adoting the same type of guidelines . In her study of Americans needing home care. Feller(1986) reported that groups other than the elderly need in-home care services. Included are one out of every ninety adults between the ages of 18-44; one out of every thirteen children between the ages of 6 and 17; and five million chronically ill Americans over age 45 who need outside assistance to continue to live independently. The highest rates are for women, unmarried people, adults alone or living with someone other than a spouse, families with income less than $10,000, and people who live in cities. (d) Shift to Ambulatory Services Medicare has drawn more than 200 procedures from inpatient to ambulatory settings. It is projected that some hospitals will reach a new plateau for ambulatory surgery with a 50-50 percent inpatient to outpatient ratio.(Daniels. 1987, p. 6) Other insurers are also moving to mandatory outpatient programs. In a continuing effort to reduce health care costs, customers try to encourage employees to use less costly outpatient facitilies.(Pennsylvania Blue Shield, 1987) (N.Y. Times. August 2. l987) Some outpatient procedures are appropriate for home care visits. Nurses can teach, observe, reassure, provide direct care on the evening of outpatient surgery and the next day. and report findings to the physician. As noted by Taylor earlier in this report, these patients. however, are not tracked for discharge planning and referral to home care agencies. Internal Factors Affecting Home Health Services There are multiple internal factors that must be considered in light of the impact of DRGs. (a) Productivity Since reimbursement is based on a per visit basis. staff productivity becomes an important issue. Agency budgets are directly related to this 15 concept. Nhere caseloads are low or fluctuating. the use of part-time or per diem staff may meet one identified need but present another consideration. Part—time personnel present new problems for both staff and administrators in regard to the continuity of care as well as staff availability. They also may be less productive. . In addition to the acuity level of patient care, the introduction of the Standardized Medicare Plan of Treatment Forms 485.486. and 487 had a major impact on productivity in September 1985. At the VNA-EMC, staff productivity has been monitored on a monthly basis. calculated for individual staff members and as a total for each discipline. The average productivity of 5.6 visits per day(VPD) in April 1985 decreased to 5.2 in September 1985, and 5.1 VPD in October 1985. Office time increased from 31 percent in April of that year to 33 percent the following September and October.(Harris, 1987) As of September 1987, productivity has not returned to the 1985 level. (h) Documentation For several reasons, documentation is essential: to meet professional responsibilities and standards; reimbursement; coordination and continuity of care; quality assurance; and risk management, Without question, the introduction of‘ Forms 485, 486 and 487 has had a significant impact on both documentation and productivity; Its effect has been felt by physicians and staff on a clinical level and by the home health agency on a financial level. Financial ramifications have been manifested in several ways through (1) decreased productivity, (2) decreased reimbursement due to technical and medical denials, and (3) increased staff needed to oversee in-house quality control efforts. (c) Methods of Documentation of Increased Costs At present, one of the identified problems in home care is the lack of uniform data collection by all home health agencies. Another concern is that a dearth of agencies use a patient classification system(PCS), includingv nursing diagnosis(ND) as a basis for documenting care, or to identify the cost of providing care required by patients with different expect outcomes. A survey conducted by MARNA in July 1987 indicated that 55.5 percent of the respondents employ a PCS, but only 22.5 percent use it as a mechanism for costing out nursing in their agencies. Although all of the nine agencies surveyed reported a system for costing- out nursing, only one implemented it 16 as a result of DRGs. It is understandable why agency administrators do no necessarily place a high priority on introducing the new documentation requirements. They are faced with the reality of coping with financial survival issues, increased denial rates, loss of waiveof liability, lack of payment under waiver. proposed revised Forms 485 and 486 in late 1987, and decreased visits along with increased acuity levels of patients. Nhy introduce a new documentation system when the one currently in use meets Medicare certification requirements? I believe that home health administrators must give priority to identifying the cost of provid— ing home care services by various methods other than the present cost per visit basis. Administrators must be prepared to manage in a PPS in home care for the future. Val Halamandaris(1985, p.8) stated that the general perception of the U.S. Congress is that DRGs have been a success, or at least enough of a success for Medicare to move in the direction of PPS for nursing homes, home health agencies, and perhaps even for physicians. (d) Patient Classification Systems(PCS) An alternate method to document the impact of DRGs is the use of a PCS, which along with nursing diagnosis enables an agency to identify patients who require the most resources and time, and the dollars associated with each category. At the VNAuEMC, we have adapted the Visiting Nurse Association of New Haven's(1980) Rehabilitation Potential Patient Classification System(RPPCS). For several years, we have monitored the number of patients in each of the five categories, length of stay, cost per case, and those categories most costly to staff. The use of nursing diagnoses as a PCS also serves several purposes: (l) to identify nursing problems, (2) to use as a nursing care plan, and (3) to cost out nursing care based on the percentage of time spent on each diagnosis.(Harris. 1987) (e) anlity Assorance (QA) Quality care is the result of a philosophy, qualified staff, sound, safe policies and procedures, evaluation, and follow through on feedback. Agency standards, including internal ones, national accreditation, certification, and licensure are essential to a comprehensive QA program. Professional standards - including individual state licensure, national and state certification, 17 orientation. and inservice and continuing education programs - are addditional safeguards to assure quality care in a changing environment. Tonges(1985) stated: "In a cost containment atmosphere, providers must either lower their standards or find ways to provide quality care more economically." Although dollars, not need, may increasingly determine the level and amount of care that home care patients receive, administrators and staff must find ways to promote quality more economically. We cannot lower standards of patient care. Quality Assurance must encompass financial outcomes(what goal was obtained at what price?), so that administrators can monitor costs as well answer the question: Does a higher or lower than average cost per case, discipline, or diagnosis mean that quality care was or was not provided? Harris, Peters and Yuan(1987) described the results of this type of evaluation process at one home health agency. Additional Factors Affecting Home Health Services Other factors must be considered in today's health care environment such as: (1) Agency Policies and Procedures. It is important to address such issues as who is accepted for care, under what circumstances, and for how long a period of time. (2) Working relationships with physicians and discharge planners - good referral information. (3) Evaluation of home care environment. Who is the care giver? What is the physical layout of the home? Can care be provided safely? (4) Patient and family impression of illness and service required (need versus want). (5) Morale issues fOr all levels of staff. (6) Supportive board of directors and professional advisory committee. The effect of DRGs also present ethical considerations. Several l8 questions to be addressed include: (1) Once admitted for care, which patients shall receive what amount of care, by what level of personnel, and for how long? (2) When are patients discharged? (3) Should patients who do not have third—party insurance coverage, or refuse to divulge financial infonnation, be given care at a reduced fee? (4) Is it the role and responsibility of a voluntary organization to use contributed dollars to fund government decreases for covered services? In June l986, HCFA issued a bulletin stating that the prefilling of insulin syringes was no longerconsidereda skilled nursing activity under the Medicare program, unless this activity was offered as part of the cost of another skilled nursing visit. This type of decision was contrary to good nursing practice. Anne Somers(l986, p. 1) stated that "the idea of not dying, but still not getting well - in other words having to live with a chronic illness or disability for the rest of your life - that was Just not a concept which was recongized at the time Medicare was passed." This observation seems to applicable in today's climate. Diabetes, Multiple Sclerosis, and cardiac problems exemplify the kinds of diagnoses being questioned for Medicare coverage at home. The process of risk management, another vital concern of administrators in dealing with DRGs, has to include staff and contractor selection, orientation, inservice education, standardized procedures, documentation, competency of caregivers, 24-hour call for staff. employee health insurance coverage, and hi-tech procedures. These activities contribute to the cost of providing services in a shrinking economy. Effects of DRGs on Various Groups Staff The present home health care environment significantly affects all levels of staff. Staff nurses must be clinically skilled, possess or improve documentation skills to avoid technical or medical denials. be knowledgeable about all third-party regulations, maintain productivity standards, and 19 provide quality care. Home health agencies recruit nurses with intensive care experience. Marlene Kramer(1974, p.vii) uses the term "reality shock" to describe the phenomenon and specific shocklike reactions of new workers who find themselves in a work situation in which they thought they were being prepared, and then suddenly discover that this was not the case. She focuses on the discrepancy between the educational and practice environ- ments and the reactions that follow,when the aspiringprofessional perceives many ideals and values not operating as well as going unrewarded in the work situation. Professional-bureaucratic conflict occurs in bureaucratic settings. (Kramer, 1974, p. ll) The contemporary world of DRGs and the community health environment demonstrate this type of conflict. Here is an example. Some time ago, a new staff nurse returned to our headquarters and questioned her ability to continue as a community health nurse. It appeared that the family of a terminally ill patient was not providing care as instructed nor administering the medications and diet. Conditions in the home proved to be less than ideal. The nurse came into my office in tears, stating: "No one told me it would be like this." On questioning her further, I found that her doubts and frustrations stemmed from the notion that , as a caring person, she should be able to make a difference - and in this specific situation, it was not possible. This nurse stayed with the agency and became a "good" community health nurse, but her own reality shock was understandable. Patients and Families When there are responsible, capable family members to care for the more acutely ill individual, we may be placing an excessive burden on them. We require them to be responsible for self-care programs for many hi-tech procedures. This is true for hospice patients where we share responsibility for pain management with the family, as well as with families with a member dependent on a ventilator or intrvenous feedings. In reality, many of these hi-tech patients are in specialized areas in the acute care setting with a 24uhour surveillance. When they return home, however, they become totally dependent on qualified lay persons, supplemented by intermittent 20 skilled nursing care. According to a National Council on Aging study, 23 percent of Medicare patients in Michigan, who had been independent before hospitalization. indicated that they were unable to care for themselves after discharge. 0f the 576 respondents in the sample, hospitalized between October 1985 and March 1986, more than one in ten believed their length of stay was too brief. Thirteen percent reported that the time period was inadequate to treat their health problems. About twouthirdbwere later re-admitted for the same condition. After an average of 91 days, approximately 25 percent were rehospitalized with original conditions.(Daniels, 1987) Moyer(1986) conducted a study to examine outcomes following Medicare home health services for one type of caregiving family unit - the married couple. She interviewed 58 elderly subjects whose spouses recently received Medicare-reimbursed home health services. The care-receiving spouses were required to have been discharged from the home health agency in "stable" condition. The couples lived alone in their own homes, with no other family members sharing the residence. The most notable outcomes included a 20 percent hospitalization rate and 10 percent mortality rate among the care-receiving spouses two to three months after discharge. Moyer noted that the rates of hospitalization and mortality among care-receiving spouses appeared alarmingly high. given that each of the individuals had been appraised as stable, or no longer in need of skilled care at home care termination. This observation suggested that, in some cases, patients may be discharged from home prematurely. It may be that the Medicare program is defeating its aim by encouraging/reimbursing very short-term services. If patients are being discharged prematurely and are unnecessarily requiring hospital care or are dying during a quite brief period after the termination of home health services, then those services may not have been cost-effective. A encies ' In December 1985, the Home Health Agency Assembly of New Jersey forme an ethics committee.(Pignatello. Moulton & Eng, 1987) One Of the committee's first tasks was to elicit from agency administrators and staff their perceptions of the most pressing issues. Responses were gathered via 21 questionnaires and telephone interviews. The following problems were identified: l. Trying to maintain agency solvency while meeting minimum basic home health care needs of patients and families. 2. Ensure employee safety with compromising patient care. 3. Maintaining an agency‘s standard of productivity while meeting, in a qualified manner, the increasingly complex care needs of patients and families 4. Addressing treatment decisions and truth— telling issues in the care of the terminally or incurably ill. 5. Dealing with patient abuse/neglect of children and adult. 6. Meeting patient needs and demands as well those of caregivers when such needs/demands conflict. 7. Resolving conflicts with physicians whose intervention or lack of intervention is determined to be not in the patient‘s best interest. The provision of hi-tech services has several effects on home care agencies. Adequate time and levels of staff are necessary to provide service to these patients. This means that agencies must have staff skilled in selected procedures. It sometimes requires two nurses to go on a single visit for observation and return demonstration, or Spending time in the institution to learn a new procedure; Also, additional costs may be incurred in several ways, such as increased length of visit along with having additional staff skilled in hi-tech care on call to neat emergency needs. Home care is reimbursed on a per visit basis. We receive the same per cost visit rate regardless of the length of time. A high-tech visit may require two to three hours of time rather than the usual fifty minutes. This practice decreases overall agency reimbursement as well as increase the cost per visit. The result is a negative impact on the budget's bottom line. 22 Physicians The most easily identified effect on physicians is the increased amount of paperwork that results from the use of the uniform plan of treatment forms. as well as frequent admissions to and discharges from home health services for the same patients. Agencies depend on the signed physicians' orders for both patient care and reimbursement. Physicians must be informed about the need for timely submission of forms so that agencies can meet the requirements of the Medicare program. Baccalaureate Nursing Education DRGs have created inevitable side effects on baccalaureate education. An agency must detennine whether it is willing to continue or expand existing observational or practicum experiences for students. Also; there is the increased need for an expanded curriculum to prepare the new graduate for the present environment. Exhibit B provides a list of considerations important to the future education of students. Challenges to Nursingv Home health care is in a state of constant change as a result of DRGs and other factors as discussed in this paper. Our challenge is to provide quality care to patients and their families. Yet. in this reim- bursement environment, the concept of community health nursing may be lost. To illustrate: Nurses care for the patients but they cannot take the time for preventive services, such as taking vital signs of other family members, and doing referral and follow-up after detecting a problem . which, in turn, would reduce the overall health care costs by possibly everting unnecessary hospitalization. The current system has made it necessary to do what is essential in one home and move on to the next reimbursable visit. Nurses must be prepared to provide cost-effective health care services of quality in both the curative and preventive realms. It is ironic that the Medicare system, established to provide health care for the elderly and disabled, now prevents some populations from using the benefits and denys needed care to others/ Nurses must help to determine the future of patient care. and participate in a re-examination of the entire health care system. We need to study the system in light of the impact of DRGs on community health nurses and the nursing shortage. Frustration. paperwork, 23 and the lack of opportunity to use professional judgment( a reviewer in a distant office determines if services are needed, and not the professional in the home)are a reality in l987. ‘These are a few of the issues to be consideredas we prepare community health nurses for now and the future. Opportunities and Limitations Multiple opportunities exist for community health nurses. Included are the development of patient educational materials; cultivation of relationships with discharge planners and physicians to stimulate use of and involvement with community programs such as caregivers in the workplace; and the development and sale of computer software to meet the documentation requirements. Other opportunities include working for changes in legislation to benefit the patient and family,-and the nursing profession. A specific example applicable to home care would be pronouncement of death by registered nurses. At the federal and state levels. there are opportunities to be involved in professional and trade organizations and to serve on boards or committees. Among the limitations is the significant decrease in numbers of community health associations willing to accept student placement. Some of the reasons cited are: lack of work for full-time staff due to increasing caseloads; impact on staff productivity; documentation requirements; lack of reimbursement for student placements(such as dollars, continuing education courses); and increased staff time required for internal monitoring of student program, and reviewing of documentation. 24 References American Association of Retired Persons(danuary,1987),*‘Can Vivers in the Workplace. Washington, D.C.: AARP. Daniels, K.(August, 1987). Home Health Management Advisor, 12. Daubert, E. (July, 1979). Patient classification system and outcome criteria. Nursing Outlook, 127, 450-454. Feller, 8. (July, 1986). Americans needing home health care. Home Health Journal, 17 (7), 1,7. Halamadaris, V.(Ocotober, 1985). The future of home care. Caring, 4-11. Harris, M.(l987). The cost of home care by nursing diagnosis, In M, Harris (Ed.), Home Health Administration. Owings Mills, MD: National Health Publishing. Health Care Financing Administration(1984). Medicare home health agency services: Persons served, visits, charges and‘reimbursement by census region and state within division. Washington, D.C.: HCFA. Kramer, M.(1974). Reality Shock. St. Louis, MO: C.V. Mosby Comapny. Lavizzo-Maurey, M.D., Laskowski, R., M.D., Harris, M., Parente, C.(May, 1987). improving drug regimens for the homebound, American Journal of Nursing, 87 5 , 593-596. Mid-Atlantic Regional Nursing Association.(l987). DRG Survey. New York: MARNA. Out-patients are in.(1987). New York Times, 2 August, Sec. 3, l. Moyer, N (may, 1986). Outcomes after termination of medicare hom health services; Their relationship to the resources and well-being of elderly caregiving spouses. Unpublished doctoral dissertation, University of Pennsylvania School of Nursing, Philadelphia, PA. National Association for Home Care. (March 193 1986). The attempted dismantling of the medicare home health benefit . Report to Congress. National Association for Home Care. (August 7, 1987), NAHC report , Report No. 225. Harris, M., Peters, 0., 8 Yuan, J.(May. 1987). Relating quality and cost in a home health care agency. 958, 13(5), 175«181. Pennsylvania Association of Home Health Agencies.(August 6, 1987). The home health industry of Pennsylvania and its'Medicaregpatients are victimized 5y Medicare program’?ailures. Harrisburg: PAHHA. Pennsylvania Association of Home Health Agencies. (1986), 1986 home health agency survey. Harrisburg: PAHHA. 25 Pennsylvania Association of Home Health Agencies (1987). Claims denial survey, July 1987. Harrisburg: PA, HHA. Pennsylvania Blue Shield (1987). PRN -4policy'review and news, summer 1987 (p. 4). Camp Hill: PBS. Pignatello, C., Moulton, P., & Eng M. (1987). Ethical concerns of home health administrators: The day to day issues. In M. Harris (Ed.). Home Health Administration. Owings Mills: National Health Publishing. Rak, K. (Ed.). (1980). Home health. line decade report - 1980. Washington, D.C. Senate Committee on Aging (July 28, 1986). The crisis in home health care: Greater needliless care. , U.S. Senate: Sen. John Heinz, Ch. Washington, D.C. Somers, A. (October 9-10, 1986). Preventive gerontology: Contradiction in terms or key to future health care? Paper presented at Annual Meeting of the Pennsylvania Public Health Association. State College, PA. Taylor, M. (June, 1987). 1985 home health data. Princeton: New Jersey Home Health Agencies. Tonges, M. (1985). Quality with economy. Doing the right thing for less. Nursing Economics, 3, 205-211. Visiting Nurse Association of New Haven (1980). Patient classification/ objectives system. Methodology Manual. New Haven. 26 EXHIBIT A CASE STUDY I Mr. S. is a 73 year-old man admitted to home care following hospital discharge with a primary diagnosis of renal carcinoma with metastasis. Secondary diagnoses included unstable angina and hepatitis. On this particular visit, Mr. S. was lying in one bed and his wife in another in the same room. Hospitalized recently due to uncontrollable angina, Mrs. S. returned home from the hospital the previous day. The other person in the home was a daughter under treatment at a local mental health center. Refusing to take the prescribed medications, she was becoming increasingly agitated. The daughter also refused to go to work and offered no support to her parents. In fact, she placed an additional burden on the family. Mr. S.'s color was ashen. Although he barely opened his eyes, he smiled in recognition of me. Vital signs were: B.P. 114/70, A.P. 68 and regular, R 16. His lungs were diminished in depth and no abdominal sounds were perceptible. Speaking in a weak voice, he appeared very discouraged. He expressed concern hr his wife, believing that part of her heart condition was due to worry over his impending death and the care he required. He complained of abdominal pain. Below his right rib cage was an abdominal mass the size of a fist. During the visit, Mr. S. kept falling asleep, and had a difficult time answering questions accurately. Be is increasingly lethargic, often wincing in pain when he thinks no one is watching him. A deterioration of his condition has occurred both physically and emotionally. Mrs. S. sat up when she saw me. very short of breath, she becomes dyspneic after walking 20 feet. My plan was to instruct her on new medications and on how to conserve energy. She was extremely worried and anxious about herself and her dying husband. At this point in the visit, Mrs. S.handed me a piece of paper sent to them in the mail. The letter stated that Medicare would not pay for the nursing visits made to her husband following his hospital discharge. It pointed out that he was not homebound, which of course upset her immensely. Mr. S. had been told that he had a few weeks to live, yet Medicare would not pay for nursing care to instruct, assist, and help him. As I read the notice of Medicare Claims Determination, I was upset and frustrated. First, the Agency had not received a copy of this denial (and did not for several weeks). The patient had to hear it first. As I turned to check his lungs, the thoughtof the notice made me angry. The man could not even turn without assistance. Mr. S. had been taught his medication regimen, but as his alertness decreased he needed further instruction on how one medication affects the other. He also needed skilled observation and direct care. Mrs. S. kept mentioning the Medicare denial. I finally took the form from her and told her not to read it again. I said that I would handle it. Mrs. S. is physically and emotionally exhausted; her husband is dying. Both require skilled nursing care and home health aide service. After discussion with supervisor, nursing visits will continue to provide needed direct care and assessment of Mr. S. Service will also be made to Mrs. S. to do cardio-respiratory assessments, and to instruct her in diet, medication 27 regimen, and energy conservation. The denial will be appealed. Meanwhile the Agency bears the cost of the service. NOTE: A review of the HCFA 485 Form submitted with the bill for ’the denial visits indicated that the nurse did address homebound status. The clinical notes were excellent, and clearly documented homebound status. A "reopening request" was submitted. As of September 1987, a decision has not been made. 28 CONSIDERATIONS FOR BACCALAUREATE EDUCATION Include related information in the curriculum as itemized below. Include health care financing information. Include nursing informatics and management information systems (MIS) Include basic legal principles and Risk Management issues. Include ethical issues. Creative use of time and energy to develop teaching aids - both audio and visual - and printed matter. Encourage independent nursing decision-making based on nursing assessment. Increased awareness of national and state political issues affecting home care. Prepare graduates for "reality shock". Cultivate interest in research. Encourage client advocacy. Be willing to be a risk taker and assume responsibility for same, that is. introduction of PCS. ND. XH BIT B RATIONALE Basic sciences and basic nursing principles need to be supplemented with courses that increase awareness of the current system and how to survive it. Nursing care is influenced by an agency's reimbursement sources. Agencies are utilizing computers for statistics. billing, quality assurance, documentation and research. Increased expOSure to liability, contracts and other legal issues. The amount of care patients receive may be curtailed. Nurses need the ability to make decisions after weighing options. Nurses need to be aware of decreased patient learning time in the acute—care setting due to shortened lengths of stay and increased acuity level of illness. Community health nurses are providing care in situations where they are the only skilled observer who has frequent contact with the patient. Nursing care must be provided within a political framework. Students are taught to provide quality care. The current environment does not always allow for this to occur in the ideal setting. Example: Although administrators do want staff to provide quality care, productivity standards are monitored and communicated to staff. There are data to be collected and analyzed on a systematic basis that will contribute to more efficient methods of delivering care. The age and acuity of illness levels of home care patients may prevent them from seeking needed services. Commitment to nursing standards. Serve as a change agent. THE IMPACT OF ones on CLINICAL NURSING ' IN HOSPITAL SETTINGS Joyce E. Johnson, DNSC, RN Associate Administrator Division of Nursing The Washington Hospital Center Washington, DC 30 In 1984, Frank Shaffer, EdD, RN, Associate Executive Director of the National League for Nursing, wrote that "the hospital world under prospective payment will be a negotiated world. Every player will be competing for limited resources.“ Nursing, Shaffer believed, must enter that competitive arena prepared to “assess its profitability to the organization by subjecting readily available data to fairly straightforward analytic methods and presenting nursing services as major marketing resource and revenue-producing center of activity.“ (p. 29) Shaffer speculated that the “prospective payment policy may well be the means to establish power for nurses if they accept the change, plan for the future, and identify their value to the DRG world." (p. 29) The end result of “costing out“ nursing services, he noted, will be that "nursing worth will be valued more when its itemized cost appears on the patient bill." (p. 29) Greater prospects for power in nursing paled, however, in the minds of many nurse administrators who faced the stressed of older and sicker patients, reduced staffing, greater accountability, and financial skills and systems that lagged behind the state-of—the-art cost identification systems needed to co-exist with DRGs. Nyberg and Wolff found in l984 that “DRG panic“ was a “leading disease“ among hospital managers. (p. 17) O'Leary (l985) echoed all of these sentiments with some strong words about the impact of DRGs on clinical nursing: “Nurses rightly see DRGs as a threat to patient care as well as their own Jobs. For nursing to survive (and make no mistake, survival is at stake here), we have to view patients as products. Never before have we tallied the costs of saving lives but now ...to prove our importance in the health care system ... we must promote the dollar value of our productivity. From 'power to panic," DRGs have resulted in a melange of positive and negative effects on clinical nursing care in hospital today. Those effects of DRGs have been described as “a glass half full for nursing" (Mundinger, p. 265), and “lean but not mean; or more with no more.“ (Sovie, p. 86) The geographic maldistribution of available registered nurses confirms to many nursing administrators, particularly those in rural, secondary care facilities that the stress of the older, sicker patient presents excessive challenges in light of the current nursing shortage. Additionally, the lack of available nurses to deliver care "quicker“ is compounded by the new 31 business attitude of the health care industry today. wherein accountability is placed on nursing to delineate, justify, and predict cost impacts and containment measures. However. few financial systems are in place to assist nursing executives to proceed with cost identification and analysis. Further, the turnover in hospital leadership and nursing administrators during the last four years confirms that the health care industry has been committed to attracting the "best and the brightest“ in key administrative positions in order to achieve projected bottom line profit margins. The impact of DRGs and the nursing shortage on clinical practice demands leadership in nursing administration particularly in secondary and tertiary care settings. Such mixed effect of DRGs were reiterated in the recently conducted survey on the impact of DRGs coordinated by the Mid-Atlantic Regional Nursing Association (MARNA). Within the responses from the thirty hospitals participating in the survey, there was a "fairly even spread of positive and negative effects of DRGs on the agencies surveyed." (p. 18) Review of the past six years in the nursing literature confirms the MARNA findings, which show that time has not diminished the widespread ambivalence about the realities of clinical nursing in the DRG era. This state of ambivalence, centered on the concept of “costing out nursing", dates back to 1980 when twenty-five New Jersey hospitals began the experiment of using the prospective payment system to cut hospital costs and ultimately survive in times of fiscal uncertainty. Costing out Nursing Begins in New Jersey Prior to 1980, New Jersey hospitals were reimbursed for their services on the traditional basis of services rendered and the number of days a patient remained in the hospital. The escalating health care costs of the l970$ forced hospital adminitrators in New Jersey and throughout the U.S. to look for more cost-efficient methods of delivering quality health care. The DRG system, orginally developed by the Center for Health Service Research at Yale University, was put to an early test when the New Jersey Department of Health began an experimental prospective patient billing system in twenty-five New Jersey hospitals. The experimental prospective pricing system stimulated much research on the use and efficiency of DRG reimbursement; concern among physicians and nurses about how well quality care could be delivered during reduced and predetermined length of hospital stay; and a new and intense focus on the contribution of nursing costs to the hospital's direct patient costs. This focus on nursing accountability and “standard“ nursing costs set forth by the DRG system became the predominant theme of nurses' concerns about the impact of DRGs on clinical nursing care and on the nursing profession. In l98l, Micheletti and Toth described the difficulties of New Jersey nursing executives in evaluating their nursing department's efficiency as it related to the average nursing costs in other hospitals participating in the state's prospective payment system. According to Micheletti and Toth, the state-generated reports of hospital management included data on nursing costs, which compared costs among neighboring hospitals so that those nursing departments whose costs were below the standard were viewed as efficient by the New Jersey Department Health. (p. 38) Nursing costs, which were also compared to each individual DRG, were based on information from case mix data from l978 or l979, which was not re—evaluated in l981. This situation, in addition to the considerable concern about homogeneity within the DRG classifications, put the nursing management in the uncomfortable position of trying to justify costs without adequate, current data. Since nursing care varied according to individual patient needs, the New Jersey system left nursing in a position in which "the nursing administrator will not objectively be able to Judge why her nursing costs are above standard nursing costs." (p. 38) Micheletti and Toth said that "it seemed clear that if nursing costs are well above standard, internal pressure will be placed on nursing managers to reduce what may be perceived as a 'rich' mix." Their concern was that “in an era when the profession is focusing on family-centered primary care nursing, the inferred DRG standardization of nursing practice is an uncomfortable reality with which nursing must contend in the state of New Jersey." (p. 38) Perhaps the greatest impact of the New Jersey experience was the stimulation of research which attempted to define what comprises quality nursing care. This focus forced hOSpitals and nursing departments to identify the contribution of nursing costs to direct hospital costs. Despite the use of outdated and ill-defined data, nursing costs continued to be individually 33 compared with diagnosistic categories, thus furthering the industry's aim of reducing the “rich“ RN staff mix. This goal was facilitated by the costing out of DRGs in New Jersey and initiated the notion of registered nurses in ”oversupply.“ In retrospect, media and industry attention to the "oversupply" issue probably contributed to our current lack of registered nurses and ensured the shortage prediction for the future as well. Additional concerns about the possible negative effects of the DRG system on patient care, nursing salaries, work satisfaction, and staff retention set a tone in the nursing world that skills in finance and reimbursement had to go hand-in hand with the planning of efficient nursing care. Improving methods for allocation of nursing costs Early skepticism about the use of patient days to appropriate nursing costs (NJ Hospital Association, p. 7-8) had prompted more research on alternative methods of assigning nursing costs according to variations in service intensity and staff mix. The well-known and somewhat controversial RIMS study, initially published by the New Jersey State Department of Health in 1978, was a first attempt at measuring nursing use by relative intensity measures of nursing rather than the standard per diem calculation for nursing services. The RIMS study, the first in a series of such studies, showed that length of stay was an important variable for calculating minutes of nursing care -- a finding that supported using patient days in the calculation of nursing costs, and also that age was inversely related the total minute of nursing care. Doubts about the usefulness of the RIMS method were based on concerns about the original sample size, biases in the relationship of co-variables such as length of stay and age, and the sensitivity of the formulas used to estimate the 'true" minutes of nursing care. (Grimaldi, p. 32) The negative association between age and use of nursing services was a controversial finding that undermined the federal policy of allowing an extra eight and one half percent for routine nursing care for Medicare patients. (p. 32) And, there were doubts about the lack of a consistent, classification system that categorized nursing versus non-nursing activities . (Joel, 1983, p. 561) 34 Nevertheless, Joel wrote that it was "the conviction of organized nursing in New Jersey that RIMS deserve the same opportunity for expansion and refinement accorded to DRGs in their early period of development." (l983, p. 562) Although it was recongized that the RIM methodology needed refinement, it represented a way of more fairly identifying and distributing the costs of nursing within a varied patient population. The proliferation of patient classification systems over the past four years has reversed the inappropriate use of patient days as the sole determinant of nursing care cost. With the RIMs study leading the way, "patient acuity" became an accepted concept and gained a level of validity despite its' varied definition and reliability. Acuity, length of stay and age are currently accepted critical indicators which profile total nursing care requirements. Nursing administrators now have the tools available to quantify, qualify, and monitor the clinical requirements for patient care. Further, the health care industry has grown to acknowledge the financial indicators that characterize clinical nursing practice and utilize these data in proforma development, product line analysis, and business plan development. The precedent is set to establish nursing as a distinct cost center. "The precedent," said Joel, "has been set: nursing will emerge as a distinct cost center with patient-to-patient variations.“ (p. 562) Refining reimbursement methodology was slowly becoming seen as a way for nurses to "turn turmoil into triumph" by clearly quantifying "nursing's contribution to the financial solvency of hospital.“ Some nurses even suggested that nurses could take the lead in the DRG costing by identifying nursing costs and then assisting other departments in developing similar cost-identification systems. (Nyberg & Nolff, p. 18) Costing and Copinggwith DRGs In 1984, six New Jersey directors of nursing/vice presidents of nursing were interviewed about their views on the current relationship between DRGs and clinical nursing. The nursing directors reported that among the positive effects of DRGs were payment for the care of indigent patients, new and improved patient classification techniques, and the provision of resource use and cost information that was helpful to nursing management. (Feldman & Goldhaber, p. l9) The director said that they have learned the hard way to 35 document the care given in nursing and warned other nurses of RIMS having suspect database that needs close surveillance. They suggested that the RIM system be used as a check and balance for patient classification systems devised in local hospitals within the "context in which the patient care was given.” (p. 22) Other nurses suggested that a variable change system which involved distribution of patient days by acuity level, staffing requirements, and supply needs was essential with DRG reimbursement. (Vanderzee & Gluska, p. l4) Although there was continuing controversy about the ideal patient classification system, the pioneering prospective payment system in New Jersey left no doubt about the critical relationship between an accurate measure of the use of nursing resources, nursing costs, and nursing's accountability in the DRG system. -(Hamilton, p. l58) The New Jersey experience with quantifying the amount of nursing care required by DRGs was seen as a "step in the right direction,“ one that would lead to the Health Care Financing Administration's funding of a grant to the American Nurses‘ Association for continued study of DRG refinements for nursing care. (Lee, p. 8)) According to Toth in l984, “even the New Jersey State Department of Health recognized that a per diem rate for an illness condition implies that each and every patient with the same affliction will display identical use of nursing services (and that) this approach is insensitive to the varying amounts of nursing time consumed by patient." (p. l99) While some hospitals viewed the costing of nursing services as a threat to central institutional control, the prevailing view in progressive hospital management was that a cost-accounting system for nursing was a source of strength for the institution. (p. l99) This measurement of nursing's contribution to hospitals was seen as a way for nurses to capitalize on the dramatic changes in the health care marketplace (Fagin, l984, p. 355); nursing's “second generation“ of attempts to price its products, (Shaffer, 1985, p. 355); nursing '5 way of "working smarter" by utilizing prospective payment to gain increased control of nursing practice (Olsen, p. 26); and as a way that nursing could firmly establish itself as a revenue-producing service. (Lagona, p. l8)~ By 1985, two years after Medicare adopted the DRG system, the need to Justify nursing costs and staffing patterns according to DRGs has caused an overwhelming amount of anxiety not exclusive to the implications that nursing 36 service departments will have to maintain quality care with anticipated decreased funds. (Marram van Sevellen & Mowry, p. 32) With diminished funds from "increasing cost-containment measures, nursing administrators are doubting their freedom to execute innovative nursing care modalities.“ (p. 34) Despite a variety of studies documenting cost savings with primary nursing, there was continuing doubt about the compatibility of the expense of primary nursing with DRGs and how well the nursing profession would adjust to costing out its product, i.e., nursing care. Throughtout 1985, the continuing theme of cost accountability for nursing was predominant in the nursing literature. Nurse authors wrote about responding to DRGs with organizational restructuring (Sovie, l985); increased program development in response to DRGs (Pointer & Pointer, l985); new approach for assessing nursing workload (Halloran & Halloran, 1985); units of measure for nursing (Porter-0' Grady, l985); increased attention to the direct correlation between patient charting and reimbursement (Hoke, l985); significance of severity adjustment on prespective payment (Horn et al, l985); and a "faster movement toward a marriage of education and service" dictated by the cost accountability of DRGs (Thompson a Diers, l985) In many instances, restruturing efforts have returned to nursing the authority and responsibility for ancillary patient care services such as laboratory, respiratory therapay, laundry, pharmacy, and dietary functions. Acuity systems have proliferated in volume, with many proving sufficient information to install a variable charge system by patient acuity, staffing requirements, and patient supply need. Most important is the resource and cost information now made available to nursing administration from finance departments. ' The lack of understanding of nursing requirements in health care settings by chief financial officers has been replaced by nursing administratos who understand the principles of health care finance, and can apply these principles to both the clinical and business aspects of the industry. Clearly, in a phenomenally short period of time, nursing administration has demonstrated an ability to keep up not only with the concepts of business but in many cases set the pace for other professional in the industry. Realignment of nursing's responsibility represents to the health care industry the potential benefit of cost reduction as well as the elimination of 37 fragmented patient care while maintaining in clinical standards in both traditional and non-traditional settings. ‘ Perhaps the most exciting trend is the movement toward reunifying education and service. Although the need to employ new nursing graduates, equipped to handle the sicker and quicker phenomena has produced an interest in collaboration, it is the overriding problem of understaffing and predicted severity of the nursing shortage that continues to spur the more creative and innovative nursing leaders to reunify our profession both educationally and clinically. According to Shaffer in 1985, "the metamorphosis of the health care system has just begun." It predicted that the need for nurses to document nursing care would become even more important in the years to come. (p. 483) In this regard, third party payors and reimbursement analysts have routinely questioned care delivery based on charge audits. Throughout our region, nursing administrators confirm the increased denial of reimbursement funds based on the "if it wasn't documented, it wasn't done“ phenomena. Early in 1986, the results of a survey conducted by the American Nurses' Association Council of Nursing Administration showed that seventy-four percent of the 118 nurse administrators surveyed reported a new or renewed interest in determining nursing costs under the DRG system. (Hartley, p. 17) Nurses continued to report methods of assessing nursing cost via "the nursing intensity factor first analyzed in the New Jersey RIM studies (Prescott, 1986); classification systems which compared patient acuity and nursing resource use (Grohar et a1, 1986); nursing models using primary and team nursing (Wolf et al, 1986); and education programming that included computerized patient classification systems (Smeltzer & Flores), 1986). According to Prescott, the newness of the DRG system, coupled with the time and effort involved in conducting research, meant that the 1986 research into nursing classification system was in its infancy. (p. 43) Since the DRG system was evolutionary as well as revolutionary (Shaffer, 1985, p. 403), continued research was needed to improve the documentation of the nursing product begun in the Jersey experiment. That research, said Whitney in 1986, called for greater collaboration between service and education so that “new nursing practice methods, reimbursement plans, and management methods“ could be studied by faculty, graduate students, and staff nurses. (p. 41) "The 38 future of nursing depends on accurate documentation of the quality and effectiveness of nursing.“ (p. 41) In 1987, the continuing documentation of the costing of nursing was reported by Marquess and Pettit via their hospital‘s participation in the Medicus National Nurse Costing Project. Their conclusion was that there was no simple correlation between the percentage of registered nurse utilization and cbst. (p. 36) Other nurses suggested that nursing practice patterns should be examined for "nursing rituals that might be responsible for questionable costs of health care." (Richards et al, p. l27) According to Joel in 1987, the unfinished refinement of costing out nursing resource use has had some negative effects on nursing in New Jersey, the state with such a long experience with DRGs. "Our inability to document nursing intensity has put us in a compromising situation economically, said Joel. (p. 794) She cited collective bargaining pressures and contract problems in New Jersey arising from DRG-related economic pressures that had implications for staffing budgets and overall retention of nurses. Joel noted that the survival of nursing under DRGs was contingent upon "carrying out a philosophy of cost-efficiency at the bedside; fine-tuning unit routine, personnel utilization, and clinical programs to maximize the use of increasingly limited resources; creating and managing internal data to document the change in nursing intensity and nursing's contribution to hospital financial solvency; and costing out nursing resource consumption case by case.“ (p. 794) In light of the nursing shortage, questions of appropriate nurse-patient ratios and the related staff mix have raised new concerns regarding primary nursing as the modality of care delivery. Many institutions have already abandoned the primary nursing concepts for a new version of team nursing: nursing case management. Although this new approach to deliver care with less registered nurses has yet to be refined, it basically calls for care delivery through ancillary or unlicensed staff at the direction of the registered nurse. Questions of responsibility, liability, and accountability have yet to be answered in order to evaluate this method of nursing care delivery. This new emphasis on cost efficiency represents quite a departure from the traditional view of nursing in which according to Joel, "per diem anonymity allowed nursing to avoid any painful precision in manpower deployment, to scrutinize the efficiency of care, or to define with conviction our autonomous 39 areas of clinical decision making." (p. 794) "Nursing,' said Joel, “cannot continue in economic anonymity. We have paid the price of being victimized by a tradition of cross-subsidization and down-substitution; nurses used for both non-nursing duties and at inappropriate skill levels.” (p. 795) She observed that studies in New Jersey showed that thirty-eight percent of hospital nursing resources were used in non-nursing areas. (l983, p. 560-563) The bottom line, according to Joel and other is that the most sweeping impact of DRGs on clinical nursing care is an economic one: that the new DRG ‘ cost containment measures forced nursing to Justify patient-specific nursing costs. Nurses now have significant, direct influence on the financial solvency of their hospitals because “hospitals can survive and thrive economically where there is a cost conscious use of resources and a clinical responsiveness to patients." (p. 795) Although the process of defining and refining patient specific billing for nursing services has sent some shock waves and panic throughout the nursing profession, it now appears that nursing under the DRG system may well evolve as a medical specialty with increased power and autonomy in the years to come. Other Effects of DRGs Increased Patient Acuity The expense of hospital admission and restrictive reimbursement policies set forth by the DRG system changed both the type of patients that hospital nurses care for, and the amount of time allotted for reimbursable hospital care. In the pre-DRG era, clinical nurses could expect to care for a patient-load with a wide variation in the degree of illness and needs for nursing care. The DRG system, however, encouraged hospital admission only for patients who could not be cared for with other less expensive community-based health services. . Limitations on health care dollars under DRGs quickly resulted in admission patterns in which only the more acutely ill patients were admitted to hospitals. The result, seen by some nurses as one of the negative effects of DRGs, was ”that there was an increase in the number of patients who are sicker and older when admitted and when discharged." (Feldman & Goldhaber, p. 19) 40 This pattern of increased patient acuity remains unchanged. In the MARNA survey, ninety percent of the hospitals using the DRG system reported an increase in patient acuity. and eighty-six percent indicated a decrease in the length of stay as a result of DRGs. This pattern of an increased level of acuity, coupled with the mandatory shortening of the length of hospital stay, has a direct effect on the practice of clinical nursing in hospital settings. Renewed Attention on Discharge Planning The fact that DRGs encouraged physicians to discharge patients at the earliest possible time to save hospital costs, has focused increased attention on discharge planning as well as nurses' critical role in the discharge process. Discharge planning has now moved from the end of the nursing care plan to the beginning so that it must begin (either) before admission (Joel, l986, p. 793), or on the day of admission. (Wolf et al, 1986, p. 200) Early in the adjustment to the DRG system, the important role that nurses need to play in discharge planning was evident. Nurses, and not physicians. were viewed as the key people in making the DRG system work. by teaching patients and planning discharges that kept patient days to aeminimum. (Lee, p. 72) Nursing care was seen as such a “major factor in helping patients become well enough to be discharged.‘ (Mundinger, p. 265) Some nurses suggested that ”perhaps physicians should continue to admit patients but nurses should have the responsibility for discharging them.‘l (Halloran a Halloran). p. 1095) Along with patient teaching. discharge planning was viewed as an activity that constituted nursing (Thompson a Diers, p. 438) and another example of its contribution to hospital care. (Fagin, p. 356) Of course. primary nursing had produced a model in which nurses had “accountability, authority, and autonomy for the care of patients from admission to discharge." (Marram van Servellen A Mowry, p. 32) Now, the DRG system required greater scrutiny of the discharge plans of patients who had shorter and regulated hospital stays. According to one author, it was not unusual to see primary nurses beginning discharge planning on admission in order to assure that everything was accomplished without having to extend the patient‘s length of stay unnecessarily. (Holf et al, p. ll) 41 It was postulated that registered nurses could control the dollar by controlling the discharge of patients (Toth, p. 200). a factor that was given much attention in hospitals reeling from the effects of prospective pricing. In one study in 1986, ninety-one percent of the 118 hospitals surveyed indicated that they had made changes in their discharge planning process. (Hartley, p. l7) This type of renewed attention on discharge planning was seen by some as a positive effect of DRGs because it forced changed that would not have occurred otherwise. (Feldman & Goldhaber, p. 19) In the MARNA survey, ninety-three percent of the respondents indicated that they had a formal discharge procedure. Fifty-five percent reported that the nursing department was included in the discharge process and, in most hospitals, that responsibility was shared with social services and other hospital departments. Toward More Patient Teaching Patient teaching, another cornerstone of the nursing profession, has taken on greater importance in the DRG era. Earlier discharges and shorter hospital stays have been translated into less available time for nurses to teach patients about the variety of important issues relating to hospital post-hospital home care. The challenge for nurses has been to establish more efficient and sophisticated methods of teaching at the bedside. In many cases, this challenge was made more difficult by budget cuts. The pressure to provide quality patient education with less time and money has put a new emphasis on group teaching as a cost efficient methods, and on searching for new and different ways to package nursing information in both print and videotape formats. (Sovie, p. 88) One hospital in New Jersey created a self-care unit (SCU) in which the nurse taught the patient's family how to provide post-hospital care. On such a unit, a small number of nurses could focus on family and patient teaching in a cost-effective way. (Feldman & Goldhaber, p. l9) Other hospitals in New Jersey reported that, as a group, more patient education was one way of coping with the prospective payment system. (p. 20) In the MARNA survey, seventy-two percent of the hospitals surveyed reported an increase in patient education while ten percent reported a decrease or no change. Two agencies reported an increased reliance on patient -education materials which included using an in-house television channel, while 42 one agency actually reported beginning patient education prior to admission to the hospital. Four agencies noted concerns about the negative effect of shorter hospital stays on effective patient education, thus reinforCing the recurring theme of nursing in the DRG era: maintaining quality patient care while co-existing with the fiscal constraints of DRGs. Addressing Concerns About the Quality of Care Do DRGs enhance or diminish the quality of patient care? Early reports from New Jersey nurses were optimistic about nurses' abilities to maintain an acceptable level of patient care, while focusing on reducing the costs of hospital resources and decreasing the length of hospital stay. In 1984, six New Jersey directors of nursing/vice presidents of nursing reported no change in the quality-of-care scores at their hospital despite a slight decrease in the number of nursing care hours per patient. (Feldman & Goldhaber, p. l9) Other New Jersey nursing directors offered similar responses when asked about the impact of DRGs on patient care in their hospitals. Responses from this group of nurses included the observation that DRGs had actually improved nursing care by allowing the tracking of nursing care patterns and resources; that the things "nurses do to improve the quality of care are the same things that we do to be cost-effective;” and that the improved productivity and efficiency necessitated by DRGs could actually improve patient care. (Lee, p. 74-75) Not all responses from New Jersey health professionals were in agreement about the effect of DRGs on quality patient care. One hospital executive warned that “the thrust is to keep cutting back, and eventually, quality will be adversely affected." (p. 77) Alfred A. Alessi, M.D., co-chairman of the DRG Committee of the Medical Society of New Jersey, reported that New Jersey hospitals were in a financial squeeze that resulted in inadequate staffing in intensive care areas. "Intensive care units should have patient/nurse ratios of one-to-one.‘ said Alessi, who reported ratios of one nurse to three to five patients. (p. 77) This type of concern about the cost-cutting atmosphere of DRGs eroding quality of care was voiced early in the nursing literature (Micheleeti a Toth, p. 134) and has been a continuing theme in the last six years. In 1985, it was reported that I‘an overwhelming amount of anxiety" was associated with DRGs 43 because “nursing service departments would have to maintain quality care with anticipated decreased funds." (Marram van Servellen a Mowry, p. 32) Decreased funding for nursing staff and a potential decrease in quality could obviously affect patient recovery, which then directly affects length of hospital stay and, ultimately, hospital costs. “Nursing care.” said one nurse in 1986, "is a major factor in helping patients become well enough to be discharged.“ It is important to have I'powerful data to show how loss of nursing resources can critically impair hospital convalescence. resulting in financial losses to the hospital far in excess of the savings yielded by decreasing nursing staff.” (Mundinger, p. 265) The bottom line for the quality of care issue is: How much trimming and remodeling could a nursing department survive without a negative effect on patient care? In 1985, Shaffer pointed out the "the quality of care will become increasingly scrutinized in the future." (p. 403) He identified quality as the health care issue of the 1990s with the burden of proof resting on nursing (p. 403) In 1986, Rolf et al reported the results of their study of the impact of primary nursing on nursing costs. They emphasized that the question of costs versus quality was still undecided. 'lnformation is needed which demonstrates the relationship between the quality of care and nursing care cost.“ (p. ll) In the MARNA survey, thirty-eight percent of the respondents reported no change in the quality of care under DRGs, while forty-eight percent expressed no firm commitment to either a negative or positive effect on quality. It was noted that frustration over documentaton. patient education, decreased staff morale, increased work load, increased tension. stress. less satisfaction with patient care. and patients being re-admitted in a shorter time were all factors that made it difficult to maintain the quality of care. Whether quality has truly been affected by DRGs remains to be seen. Relating Quality to Skill Mix or Staff Early in the DRG experience in New Jersey. the skill mix of nursing staff was an important variable in the successful strategic planning for DRGS. In l980, the survey phase of the New Jersey Case-Mix Performance Study reported on the amount of time expended by all levels of nursing personnel on all shifts in response to patient needs. Nursing costs at that time were 44. estimated to reach up to thirty-five percent of patient care costs and up to fifty percent of a typical hospital's non-physician personnel budget. (Morrison & Caterinicchio, p. l) A significant observation of the investigators was the amount of time being spent by nursing personnel in carrying out functions that were not nursing, and which could be delegated to ancillary services. (p. l) According to the authors, it was the first time that "this has been documented through applied research. (p. 1) This finding illustrated the costly habit in hospitals of using skilled nursing personnel to perform activities that could be easily done by less costly personnel without endangering patient safety or the quality of care. As one author reported, ”if there was no one available to do something, nurses did it.” (Joel, 1983, p. 563) Since DRGs resulted in sicker patients needing nursing-intensve care, the challenge for nursing administrators became how to find the right staff mix, for example, that mix of registered nurses, LPNs, and ancillary personnel which would provide the most cost conscious and clinically responsive patient care. It was reported that this somewhat precarious balance between tight budgets and adequate skilled nursing care resulted in eliminations of some nursing positions in New Jersey but no large nursing layoffs. While some lost full time nursing staff, others added staff to the part time nursing pool. Some hospitals actually added RNs through improved patient classification systems. All hospitals payed stricter attention to the ratio of RNs. “Even with tight budgets under DRGs, we like to keep a high ratio of RNs to LPNs and aides," said one hospital administrator, who added that “RNs can provide everything our patients need. LPNs and aides can't. To keep the RN ratio high and costs down, we have a cadre of part-time RNs who come only when needed.“ (Lee, p. 73) How compatible primary nursing was to the ideal skill mix for DRGs generated concern among nursing administrators in the early l980s. Marram van Servellen and Mowry reported in l985 that, “there was ample evidence to suggest that primary nursing was not too costly to maintain, and that quality could be improved when more qualified staff were utilized, frequently at a reduced cost." (p. 34) Changing professional staff ratios by substituting LPNs for RNs, a staffing alternative with budget appeal, may in the long run not pay off if ommssions of care occur and hospital stay lengthens. According to Marram van 45 Servellen and Mowry, the early positive studies of the compatibility of primary nursing and DRGs would need long term assessment with data based evaluations of actual nursing process, nursing activities, nurse-patient ratios, and staff mix. (p. 35) The response of nursing administrators to the staff mix issue would be either proactive (which recognized DRGs as a vehicle to demonstrate that a professional standard of practice produces quantifiable results with more favorable impact on profits than those produced by LPNs or aides). or re-active which saw prospective payment systems as a demand for cost reduction to which the only possible response was decreasing the number and skill level of the staff. (Olsen, p. 24) The proactive preference of nursing administrators was consistently reported throughout the nursing literature. In 1985, Sovie reported that, “it was imperative that the professional mix of staff move toward an all RN staff since a RN staff can deliver the required care with fewer total nursing care hours per patient day.“ (p. 86) Wolf et al reported in l986, that despite an increased acuity level of twenty-eight percent, a primary nursing unit was able to realize a daily savings of $l.30 per patient per ORG as compared to a team nursing unit. Hartley reported that two-thirds of respondents in the ANA survey reported a shift toward a greater use of an all RN staff in response to DRGs. (p. 17) The MARNA survey supported this movement toward an RN-intensive staff. Ten of the twenty-five respondents, or thirty-four percent reported that their staff mix had changed as a result of DRGs, while eight of the ten indicated an increase in RNs or licensed staff. Also, ninety-three percent of the respondents in this survey reported vacancies in the RN categories, a finding illustrating another phenomenon of nursing in the DRG era. The current and much publicized nursing shortage appears to be occurring at a time when the staff mix ratios demand more RNs who are not available in sufficent numbers to meet the patient care needs in hospitals today. Epilogue What has the impact of DRGs been on clinical nursing care in hospital settings? No one would argue that they have had a mixed effect on nursing at the bedside in 1987. While DRGs have meant budget cuts, cost containment. and 46 increased accountability for the nursing profession, they have also been a conduit through which nursing has improved its visibility, productivity, and capacity for innovation and change. The separation of nursing charges from room charge has clearly identified nursing as a revenue-producing center within the hospital, although more research is clearly needed on patient classification systems. While DRGs have highlighted the important role nurses play in patient education and in the discharge process, they have imposed time constraints and fiscal pressures that have put additional stresses on nurses at the bedside. The MARNA survey suggests nursing's continuing ambivalence about the overall effects of DRGs on nursing care and on the nursing profession. Only long term studies can provide the type of scientific data that will make it possible for the nursing profession to judge the lasting effects of DRGs on nursing care in hospital setting. In summary, the mid-Atlantic region has exhibited a renewed interest in discharge planning as a result of the decreased patient stay and the resultant acuity continuum. Additionally, the emphasis on patient teaching, articularly the innovative packaging of educational programs for patient use, demonstrate the commitment by nursing to respond to the health care requirements both on an in-patient and out-patient basis. Critical to the success of this educational focus is the use, revision, or abandonment of primary nursing as key to the practice and definition of nursing today. Concerns about the appropriateness and quality of care have presented an opportunity and challenge for both nursing administrators and educators. It is clear that both groups must view themselves as business executives competent not only in the clinical practice field but also in the business world of the health care industry. Since 1984, contemporary nursing leaders have emerged, showing an ability to take risks in redefining the image and role of nursing at the bedside and in the administrative suite. The call for collaboration between practice and education sets the stage for reunification of our profession at a time when opportunity exists for nursing to emerge with expanded control of patient care activities and the health care dollar as well. 47 References Fagin, C. (1986). Opening the door on nursing's lost advantage. Nursing & Health Care, 1, (9). 352-357. - Feldman, J. & Goldhaber, F. (1984). Living with DRGs. The Journal of Nursing Administration, 13, (5), 19-22. Grimaldi, P. (1982). DRGs and nursing administration. Nursing Management, E) (1), 30-34. Grohar, M., Myers, J. & McSweeney, M. (1986). A comparison of patient acuity and patient resource use. The Journa1 of Nursing Administration, 16, (6), 19-23. -— Halloran, E. a Halloran, D. (1985). Exploring the ORG/nursing equatioh. The American Journal of Nursing, 85, (10), 1093-1095. Hamilton, Jr. (1984). Nursing and DRGs: proactive responses to prospective reimbursement. Nursing & Health Care, 5, (3), 153-159. Hartley, S. (1986). Effects of prospective pricing on nursing. Nursing Economics, 5, (1), 16-18. Hoke, Jr. (1985). Charting for dollars. The American Journal of Nursing, 85, (6), 658-660. Horn, 5., Sharkey, P., Chambers, A. & Horn, R. (1985). Severity of illness within DRGs. The American Journal of Public Health, 15, (10), 1195-1199. Joel, L., (1983). GRGs: the state of the art of reimbursement for nursing services. Nursing & Hea1th Care, 3, (10), 56-63. Joel, L. (1987). Reshaping nursing practice. The American Journal of Nursing. ‘81, (6), 793-795. Lagona, T. & Stritzel, M. (1984). Nursing care requirements as measured by DRGs. The Journal of Nursing Administration, 11, (5), 15-18 Lee, H. (1984). How DRGs will affect your hospital and you. 5N,.§, 71-81. Marquess, R. & Petit, B. (1987). An Analysis of the effect of percent of RN staff on nursing costs by DRG. Nursing Management, 1g, (5), 33-36. Marram van Servellen, G. & Mowry, M. (1985). DRGs and primary nursing: are they compatible? The Journal of Nursing Administration, 15, (4). 32-36. Micheletti, J. & Toth. R. (1981). Diagnosis-related groups: impact and implications. Nursing Managemen , ll, (9), 33-39. 48 Mid-At1antic Regiona1 Nursing Association. (1987). Survey on the impact of ORGs vis a vis hospita1s. Unpublished data. 1-20. New York: MRRNA Morrison. P. 8 Caterinicchio, R. (1980). Case mix project. New Jersey Nurse. 10, (5). 1, 7. 10. Mundin er, M. (1985). ORGs: a g1ass ha1f fu11 for nursing. Nursing 0ut1ook, 33, (1 ). 265. New Jersey Hospita1 Association. 1981). New Jersey Hospita1 Reimbursement Under S-446 E1ements and Effects. Princeton. New Jersey, 7-8. New Jersey SAtate Department Hea1th. (1978). A prospective reimbursement system based on patient case mix for New Jersey hospita1s. 1976-1983. Second Annua1 Report, V01. 1, Part 0. Nyberg, J. & No1ff, N. (1984). ORG panic. The Journa1 of Nursing Administration, 14, (4), 17-21. 01sen. S. (1984). The cha11enge (2) of prospective pricing; work smarter. The Journa1 of Nursing Administration. 11, (4), 22-26. O'Leary, J. (1985). Nith ORGs, b1ow your own horn. RN, 1, 87-88. Pointer, 0. a Pointer, T. (1985). 8ui1ding innovative nusing departments; thriving in the turbu1ent times. Nursing Economics. 3, (4), 73-77. Porter-O'Grady, T. (1985). Strategic p1anning; nursing practice in the PPS. Nursing Management, 16, (10), 53-57. Prescott. P. (1985). ORG prospective reimbursement: the nursing intensity factor. Nursing Management. 11. (1). 43-46. Richards. M.. Hexum, J. a Anderson, R. (1987). Patient care demands by ORG: a pi1ot study. Nursing Economics, §, (3). 126-129. Sae1tzer, C. 8 F1ores. S. (1986). ORGs: what nurses need to know. Nursing Management, 11, (10). 17-20. Shaffer, F. (1985). ORGs - Two years 1ater ... and beyond. Nursing 8 Hea1th Care. 6, (10), 403. ‘ Shaffer, F. (1984). Nursing power in the ORG wor1d. Nursing Management. lg, 6 . 28-30. Shaffer. F. (1985). Costing out nursing. pricing the product. National League for Nursing. * She1ton, J. (1985). Can nursing options cut health care's bottom 1ine? Nursing a Nea1th Care. 6, (5), 250-253. Sovie. M. (1985). Managing nursing resources in a constrained economic environment. Nursing Economics.‘§. (3). 85-94. 49 Thompson, J. & Diers D. (1985). DRGs and nursing intensity. Nursing & Hea1th Care, g, (10), 434-439. Vanderzee, H. & G1uska, G. (1984). DRGs variab1e pricing and budgeting for nursing services. The Journa1 of Nursing Administration, 13, (5), 11-14. Whitney, F. (1986). An economic view of co11aboration between nursing services and education. Nursing Economics, 4, (1), 37-40. Ho1f, 6., Lesic, L. & Leak, A. (1986). Primary nursing - the impact on nursing costs within DRGs. The Journa1 of Nursing Administration, lg, (3), 9-11. 50 THE IMPACT OF DRGs 0N BASIC NURSING EDUCATION and CURRICULUM IMPLICATIONS LuciIIe A. JoeI, Ed.D., R.N. Chairperson, Department of Adults and the Aged Rutgers, The State University of New Jersey _ CdIIege of Nursing Newark, New Jersey 51 DRGs are both a symbol of growing cost containment in health care. and a milestone event in the movement toward greater economic control. The success of DRGs hinges on reshaping the diagnostic and therapeutic management practices of physicians by restricting reimbursement to hospitals. Hospitals were originally targeted for change as the most costly component of the delivery system. DRGs were proposed as a vehicle for government and the health care industry to share the risk of providing hospital services to Medicare recipients, and to assure that acute care resources would be allocated equitably to those, who needed them most. The model promised rewards for efficient service delivery. For many hospitals, DRGs offered more risk than reward and were seen as a negative approach to cost control. More positive techniques for reshaping utilization practices have come from business and industry in the form of rewards to employees for being prudent consumers of health care. This contrast between public and private sector strategies is important: appeals to the consumer as opposed to the provider, positive versus negative reinforcement. A new mosaic of reimbursement practices has increased the acuity of hospital patients and created unrelenting pressure to decrease the length of stay and increase the volume of admissions. "High technology" has moved into home health and nursing homes as less costly settings for care. Managed care systems and ambulatory services are beginning to dominate health care, and create a critical need for case management. Delivering care is no more important than developing independence and self-sufficiency in the client and mobilizing informal resources. The growing numbers of frail elderly and chronically ill in the population create a challenge to the traditional medical ethic as functional ability becomes of equal or more importance than cure. Even these limited observations build an indisputable case for more and better prepared nurses. Too much is being expected of too few. The range of consumer need creates a market for a sophisticated corps of professionals and associates who work under their direction but are not interchangeable with them. Educational programs for entry into practice should reflect distinctions between categories of nurses and be substantially changed from the pre-DRG era. 52 An absence of change is cause for concern and raises the question of how ably nursing is responding to current reality. A recent survey of states in the jurisdiction of the Mid-Atlantic Regional Nursing Association (MARNA) is discouraging. Only 52 persent of respondents claimed any curriculum adapta- tions in response to DRGs. All of the respondents verified an observable increase in patient acuity, but 55 percent saw no need for adjustments in clinical learning. An increased emphasis on discharge planning, patient teaching and quality assurance was noted, with emphasis on patient teaching growing most noticeably in associate degree programs. Nith disturbing honesty, 72 percent of the responding schools reported no programming to update their faculty on the changing practice environment. Respondents were concerned with the acuity of hospital experiences, and the rapid turnover and decreasing numbers of hospital patients. (MARNA, 1987) Though onlytwenty-nineschools responded, the author is left with the feeling that the data are correct and nursing education is not responding adequately to the challenges of the times. This being the case, it is not surprising that graduates are disillusioned by contemporary practice, and ill-equipped to respond to the consumer need for more sophisticated service. The remainder of this paper will be used to detail more completely the changing practice environment and complementary curriculum implications. Nhere experiences of MARNA states differ from those of the nation as a whole, the point will be made. Much of the direction for change proposed in this paper is based on data and experience from the State of New Jersey, which provided the setting for initial experimentation with the DRG system. These proposals for change are not futuristic. The future is now. Talk of the future creates a safe distance, and there is nothing safe about substituting rhetoric for action. The direction of change formalized by DRGs was evident at least a decade earlier. Inaction and comfort with traditional ways require immediate attention to "damage control." The author also rejects the temptation to prove the value of nurses and nursing. Adequate proof and consumer support exist to allow us to proceed without apologizing. Nursing and the Changing Health Care System The professions grew out of social need. Their future depends on the ability to walk the fine line between acting in the best interests of the consumer and responding to changing times. The health professions as a class 53 address a very distinct cluster of human concerns. These fields of work are characterized by "soft boundaries", so that activities over time may be transferred from one provider to another or become the common property of several provider professionals simultaneously. The health care system has experienced dramatic change due to appropriate concern over the cost, quality, and availability of services.‘ It is logical to assume that the health care professions will be expected to adjust their roles accordingly. EvolUtion of DRG System Governmental concern with the cost of health care began to surface shortly after the establishment of the Medicare and Medicaid programs. Simultaneously, private sector health insurance became available to a growing number of citizens as a fringe benefit derived through the workplace. Americans began to expect first-dollar, comprehensive coverage from both .public and private sector insurers. There was little attempt to stem the tide of escalating health care cost until the presence of a federal administration, which accorded a greater priority to defense than to social welfare programs. Hospital expenses reimbursed under Part A of Medicare were quickly targeted for cost control as the most expensive aspect of the one program fully under the federal government's control. Cost predictions for the hospital management of medical and surgical conditions were developed by merging data on the prescriptive practices of physicians for Medicare recipients with the Diagnoses Related Groups Classification System (DRGs). The result was the much publicized DRG system, or more correctly the Medicare prospective pricing methodology based on case mix with episode of illness reimbursement. More significantly, government had set into motion a process that would totally transform the American health care delivery system. (Joel, l985) Controls initiated by the federal government for the Medicare system were quickly taken up by state Medicaid programs and private sector insurers. Business and industry expanded the theme of cost-efficiency and began to self- insure the health care risk of their employees as opposed to contracting with the insurance industry. This now common practice has created a private sector environment that rewards self-care and prudent buyer practices, and sees tangible benefit from investing in health. (Joel,l985) An observer might conclude that, fearing eventual government intrusion to control escalating health care costs, 54 private sector found more creative ways to reshape ultimately the delivery system to a greater extent and in a more radical manner than DRGs. The roles and responsibilities of provider professionals will have to be reassessed to complement an economically driven practice environment. The watchwords have become Self-care, home and community-based services, case coordination and integration of services, information management, high technology, client advocacy and personal accountability for care. Within a health care delivery system ensnared in complex calculations and regulations, there exists the expectation that operations should be fine-tuned to avoid waste and that only the most cost—efficient providers, settings, and services are justified. Nurses have always been the most visible and continual providers in the delivery system. Nurses have traditionally coordinated and integrated the treatment regimen, advocated for the client, and counselled and taught with the goal of returning the recipient of care to self-sufficiency and independence. "The nurse has created order out of chaos and health out of illness....Nurses hold patients' dignity in their hands more often than their lives....Nurses have come to view peaceful death as a therapeutic triumph." (Lang,1987) The restructuring health care delivery system creates a temporary window of opportunity for these historical strengths of nursing. Should nurses be hesitant, other providers will expand their boundaries to fill the breach or new providers will be created. Society created the physician's assistant in times of physician undersupply and the licensed practical nurse as a response to a nurse shortage in past years. Social workers are functioning as case managers and discharge planners. Health educators intrude on the comprehensive care that characterizes nursing. Nurses are captive to bioengineers who,by controlling high technology, often stand between nurses and their patients. As their own surplus grows, physicians begin to encroach upon the practice of nursing. Salaried physicians could be proposed as a remedy to the shortage of critical care nurses. History will repeat itself. During physician shortages earlier in this century, nurses expanded their practice to include physical examinations, immunization, and additional well-child activities that were reclaimed by physicians as their numbers increased. (DeMaio, l979) 55 Nursingjs Highly Interactive Tradition Reimbursement models are creating a highly interactive future for health care. Movement is toward capitated financing and managed care systems which will eventually limit both community and institutional resources. High acuity will characterize the consumer in the health care delivery system. Fragmenta- tion and complexity will pose constant threat to continuity and comprehensive care. Case coordination and service integration will cut cost and become desirable, if not essential. The role provides a perfect fit for nurses, but has not been claimed either by nurses or for nursing. In public prOgrams such as long-term home care, where case coordinator positions exist, regulations alternately accept social workers or nurses for these roles. The business literature presents case coordination as a Significant enhancement to cost-efficiency. Industry reports a $3.00 per employee return on a $1.00 per employee investment into a combination of case coordination and utilization review. (Naisbitt and Aburdene, l985) In other instances, comparable services have yielded an overall twenty percent reduction in medical claims cost. (Rutigliano, l985) Such programs have provided for precertifica- tion of reimbursement limits, employee counseling concerning options in clinical management, advocacy in dealings with provider professionals (should the employee express need), and analysis and policy development in large volume claims areas. In a reported audit of employee claims for non-surgical hospital treatment of lower back pain, eighty-five percent of in-patient days were determined to be inappropriate. An expert panel gave opinion that the prevailing prescription of bed rest and medication was cheaper and safer at home with appropriate home care support. Policies were subsequently revised to reflect new reimbursement parameters. (Rutigliano, 1985) This marriage of sophisticated clinical judgment and reimbursement policy is particularly significant in this case since medical treatment of lower back pain appears to be an exceptionally high volume DRG. By example, it is the most frequent DRG in the State of New Jersey. (New Jersey Department of Health, 1985) Maximizing an individual's personal resources is no less challenging than integrating the health care system in his behalf. Rewards will be offered for self-care and the supplementary use of services provided by friends, family, and volunteers. Quite logically, care is given most carefully by those who care. 56 Provider professionals who can develop resources that do not add to the cost of the system, eliminate duplication, and reshape consumer utilization practices will move into controlling positions. Advocacy will be visible and valued by the consumer, who in fact has become the most significant player in the health care game. The role components presented here, human resource development- coordination-advocacy,are representative of services nurses have historically provided. If pieces have slipped from our.grasp, they must be reclaimed. Curriculum implications call for a renewed appreciation of the psycho- social and interactive aspects of practice which have traditionally been strong in nursing. Nursing is the most highly interactive discipline in a highly interactive environment. This characteristic derives from the intimate and holistic nature of the service. The unique nurse-client relationship should be dignified in the curriculum by a practice framework that promotes the relevance of nursing to the times. The nurse complements the clients' deficits in self- care toward the end of providing resources in a manner clients would select for themselves, always promoting self-sufficiency and independence. This philosophy’becomes highly marketable as it contributes to cost-efficiency in modern health care. Building on this theme, priority must be accorded to discharge planning, and teaching and counselling as therapeutic techniques to develop self-sufficiency. The ability to establish excellent interdisciplinary relations is another guaranteed route to cost saving, which is highly dependent on skilled inter- action. In this situation, strong oractice credibility and the capacity to function as part of a team are prerequisites to success. Consumers have become intolerant of turf disputes between provider professionals that have the net effect of diverting energy from the mission of health care delivery. The nature of professions demands that territorial boundaries between areas of practice remain flexible. Time and social interaction necessary require a periodic realignment of activity areas between disciplines. Tolerance for ambiguity, flexibility and very few vested interests serve the consumer interest best. Though interdisciplinary experiences are a required component of nursing education programs, this dimension of practice deserves more serious attention in the l9805. The ideal route to developing interdisciplinary respect and understanding is shared educational experience. The best of all worlds would include a health science core of studies and a clinical laboratory, which allowed students from a 57 variety of disciplines to interact and jointly provide care. Given reality, educators should at least search out practice settings for students that allow participation in a multidisciplinary team. Rutgers College of Nursing created this learning situation within the Teaching Nursing Home Project. All of the clinical strategic planning for the Project was accomplished through the vehicle of a multidisciplinary team which included nursing, medicine, occupational and recreational therapy, dietary, physiotherapy, pharmacy, administration, chaplancy, and volunteer services. Students participated freely and reported more comfort in their day-to-day dealings with these provider groups as a consequence of that participation. (Rutgers College of Nursing, 1987) It should be noted that the peer relation- ship for students is compromised when they participate on a team consisting of established providers as opposed to students learning the discipline. The complexity of practice mounts as nurses participate in a work force with a variety of skill levels. In view of the growing number of chronically ill and frail elderly, there are many lower-level activities in a therapeutic plan which self-care and family cannot accomplish, but must be done. The nursing shortage creates further enticement to fill vacancies with non-professionals. 1 Between 1980 and 1985, New Jersey's rank among states dropped from 15th to 32nd in relation to the number of registered nurses per lOOO hospital admissions. (New Jersey State Nurses' Association, 1987) The absence of more detailed information makes it impossible to determine how much of this effect has been due to substituting non-professionals for registered nurses, and how much derives from the complete elimination of registered nurse positions. Even assuming some combination of these circumstances, registered nurses are being expected to function with fewer traditional resources and to delegate activities to ancillary workers while retaining responsibility. Quick interpretation may create the picture of a return to outmoded models of supervision...layer on layer of people watching one another. Cost-consciousness is promoting new and better uses of the lesser skills of licensed practical nurses, nursing aides, volunteers and even of patients them- selves and their families. Industrial psychology has created a large body of knowledge in human resource development. The modus operandi has become that of working with people to get them to internalize those values held by the leader or philosophically established by the system. The system may be the client, hospital. 58 home health agency, primary nurse, or all of the above. Once subordinates understand and internalize these values, the amount of supervision necessary is reduced. (Naisbitt and Aburdene, 1985) A natural first step toward helping others to internalize values is to clarify one's own values and become clear about one's own philosophy of care and ethical style. These insights should be developed in the educational program. The Clinical Laboratory Both public and private sector reimbursement policy discourages the use of full-service, residential programs such as hospitals and nursing homes. Community-based settings represent a cost-efficient option that have not been adequately funded for either Medicare or Medicaid recipients. Private sector insUrers have been more creative in reimbursing for community alternatives. In developing the curriculum implications that stem from observations of the restructuring delivery system, ambulatory and home health must be distinguished as separate settings for community care. Ambulatory care, including the burgeon- ing health market, has never been strategically or adequately developed by nursing. Home care has been an historic bastion of nursing. Community practice could minimize some of the variables that have significantly contributed to an impoverished work environment for nurses, such as autonomy constraints, physician domination, and direct access to clients. The Community Nursing Services and Ambulatory Care Act of l987 currently before the 100th Congress enables reimbursement to nurses under Part B of Medicare without physician supervision or prescription. (American Nurses‘ Association, February 1987) The future looks bright for this legislation, and, if passed and maximized, it could establish community practice as an ideal employment setting for nurses. The home health sector is at present in a stagnating, if not deteriorating condition. An ANA/AMA paper authored at the beginning of the DRG era predicted a 300 percent increase in the volume of home care visits once the full effect of the Medicare prospective pricing system was felt. (American Nurses' Assoc1ation. 1984) This forecast was dependent on the cost-efficiency of home care as opposed to hospitals or nursing homes; close connections between hospitals and community programs which would enhance referrals; and the need for continuing care created by early hospital discharge. Futurists failed to anticipate the effect public policy would have on the growth of home care. 59 Medica1 and technica1 denia1s for home care services reimbursed through medicare have increased dramatica11y since DRGs were instituted in October of 1983. Denia1s increased from 18,121 in the 1ast quarter of 1983 to 47,855 during the first quarter of 1986. (Senate Committee, 1986) Home care agencies have compromised themse1ves by becoming dependent on Medicare reimbursement and neg1ecting to diversify their services and payor sources. In New Jersey over three quarters of 311 home visits made during 1985 were to the e1der1y. (New Jersey Home Hea1th Assemb1y, 1987) Stringent definitions of "home bound" and "intermittent care" contribute significant1y to denia1s. Legis1ation sponsored by Senator Bi11 Brad1ey of New Jersey promises to revise these criteria for more rea1istic app1ication. Modified pub1ic po1icy cou1d he1p revita1ize home care. The changing times have a1so created new hospita1 admission patterns. Same— day patients are a significant cohort infrequentiy referred to home care. Discharge p1anning has become fragmented from the nursing ro1e without progress. ing at a pace compatib1e with the needs of the same-day patient. Largeiy, these patients become 1ost to after-care. In our eagerness to adjust to increased acuity and inf1uence the 1ength of stay, nursing sacrificed continuity that wou1d u1timate1y offer the greatest cost-saving. We are 1eft with the rea1ity of a documented 37 percent increase in hospita1 discharges to home hea1th frOm 1983 to 1985, but on1y an 8 percent increase in Medicare visits for 1984. Even that modest increase offers 1itt1e security for the future of nursing in home care once the nature of these visits is more carefu11y characterized. Data co11ected in the State of New Jersey suggest that a dec1ining proportion of these visits invo1ve registered nurses. Home care aides, technicians, and therapists of a vast variety dominate the home hea1th scene. (Joe1, 1985) It wou1d seem time1y to reconsider the manpower mix appropriate to home care, degree of supervision necessary to safeguard the pub1ic, and who supervises whom. Community hea1th can on1y be reciaimed with "the best and the brightest," yet careers in this practice setting have not been appea1ing. According to American Nurses' Association statistics, approximate1y 5 percent of emp1oyed nurses worked in community settings (exc1uding schoo1 nurses) in 1970. By 1980 the percent had risen to 6.6, but five years 1ater on1y 6.8 percent of nurses were emp1oyed in the community. (Johnson, 1985) It shou1d be noted that most 60 facu1ty, except for those with a specia1ty in community or pubTic hea1th, have been socia1ized to hospita1 practice. Further, community nursing has been depicted as a practice area that first requires experience in hospital practice. These biases are conveyed both subt1e1y and direct1y to students by facu1ty. The time and space devoted to this discussion of community nursing are justified. Prob1ems in community nursing cannot be denied, but neither can the fact that the health care system is moving in that direction. Genera] hospita1s report 50 mi11ion fewer in-patient days in 1986 than 1981. More than 40,000 acute care beds have c1osed since 1983. (Aiken and Mu11inix, 1987) Regu1ations pending in the State of New Jersey wi11 adjust rates for the vo1ume of in-patient admissions, thereby providing incentives for cost-efficient hospita1s and eventua11y squeezing others out of business. (New Jersey Hea1th Care Administration Board, 1987) The emphasis accorded community nursing in its broadest sense is at best token in most educationa1 programs. This situation c1ose1y resemb1es the invisibi1ity of geronto1ogica1 nursing. Just as home care is not a11 of community nursing, the aged are not just o1der adu1ts. In both instances, the predominant market and c1ient of today and tomorrow has been disenfranchised. In defense of our future, the curricu1um shou1d provide a wide variety, and a generous quantity of community experiences. The hea1th market shou1d be sing1ed out for student experiences. Prejudices against using technica1 nurses in home care shou1d be reassessed. Graduate preparation in community hea1th shou1d, of necessity, require functiona] preparation for midd1e management. Practicum diversification should not be 1imited to diversified c1inica1 popu1ations and settings. Ne artfu11y hide the fact that diversity from many perspectives is possib1e through a nursing career. The course of studies shou1d introduce the opportunities avai1ab1e to the intrapreneur. Nurses are 1arge1y sa1aried emp10yees and seem 1ike1y to continue in that mode1. It becomes the responsibiTity of education to high1ight the freedom and cha11enge that can be created in forma1 emp10yment settings. Intrapreneurs are those risk-takers who approach invention within organized systems. They refuse to re1inquish the right to excitement just because they are sa1aried. (Naisbitt and Aburdene, 1985) Intrapreneurs have a ta1ent for negotiating high1y comp1ex systems, and are ski11ed in searching-out and maximiz- ing resources that the system affords. (pinchot, 1985) Nurses are masterfuT at 61 systems negotiation. They have brought these talents to health care for generations. Such abilities, which have only been informally documented, could be reinforced and strengthened by a systems orientation within the curriculum. Neither do nurses have to commit their lives to direct patient care in order to contribute to the world of nursing. For example, positions in utilization review and case coordination are uniquely suited to nurses and have already been mentioned. Nurses are needed in government, organizational work, and so on. Many of these new opportunities can track their origins to DRGs. Nurses are quick to criticize one another and quicker to exclude those who dare to strike out in a non-traditional direction. Attraction to an atypical nursing role is often misconstrued as failure to survive in nursing. Nurses should be encouraged to pursue new roles, claim them for nurses and nursing, and use them as a platform to advocate for their colleagues. Emergent practice roles as described in this paper cause us to admit that the setting for clinical experiences may be less important than the role models provided and the role behaviors allowed. Faculty are not the role models for students, except in those rare instances in which faculty teach on their own panel of patients. Although faculty practice is the ultimate aim of many education-service collaborative efforts, this mission often becomes lost over time. One of the most successful and emotionally uplifting aspects of the Rutgers Teaching Nursing Home Project has been the rich learning experiences afforded students by being assigned directly to registered nurses employed at the home. Those nurses, who had a wide variety of entry-level preparations, were quick to allow students to test their clinical and management skills. The nurses welcomed students' help in evaluating ancillary workers, and making decisions on appropriate delegation. At first, where students were allowed a choice of clinical placements, they were reluctant to select experience based in a nursing home. Over time a waiting list had to be established for placement in the Teaching Nursing Home. (Rutgers College of Nursing, l987) Retrospectively, students reported the Teach- ing Nursing Home as the clinical experience most relevant to their world of work. The rising acuity of hospital patients has also renewed interest in the use of service agency staff as preceptors to students. It is almost impossible for a single instructor to supervise the activities of ten students taking care of extremely ill patients requiring highly complex care. The author does not mean to 62 challenge the one instructor to ten student ratio required by regulation in many states. but to suggest that the use of staff as auxiliary teachers and preceptors be maximized. There is the constant assumption that faculty are on site and in control. In addition, the art and science of clinical teaching lie in the case presentation and analysis that takes place in pre- and post-clinical conference. The author has observed that staff rise to the occasion and profit psychologically, attitudinally, and technically from being selected to work with students. (Patterson, 1987) Professionals have traditionally assumed responsibility for neophytes entering their field. In seeking to divorce ourselves from our roots, we have rejected many good aspects of apprenticeship education. New Behaviors for the 80's DRGs have started us along a path that allows less subjectivity, and demands accountability from provider professionals. Personal accountability to the recipient of service has always been a hallmark of professionalism. This quality became less common as the health care system grew in cost and provider dominance. Recent history has reversed that pattern, placing the consumer in a position of control. Professionals are being held accountable for themselves and in a real way for the practice of their colleagues. This theme has been acted out within nursing through the growing tendency to decentralize clinical management decisions. The most familiar example is primary nursing. To be fully responsible for one's self requires a practice autonomy and clarity of purpose that is frequently at odds with the role of the salaried professional. Proper socialization into accountability takes time and support. A commitment to peer review should be established early in the educational program. Peer review should be a regular component of clinical conferencing. Students need to evaluate one another continually as peers at similar levels of development. Every ministration and design element in care should be tracked to its ultimate outcome and evaluated in tenns of a standard. The standard used to judqe one's own practice is constantly changing and often becomes a matter of conscience. Comfort in practice is only possible with a continual program of updating, a healthy respect for research, and a model for ethical decision-making. It is a respect for research that motivates staff nurses to incorporate new approaches to care into their clinical repertoire. Also it is the ethical orientation that causes the nurse to weigh alternatives rather than 63 act automatically. This openness to change and innovation is first seeded in a learning environment that provides few answers and demands persona] searches for truth. The requisite research and ethical studies are clear. A complementary strategy might be to require a self-guided review of the literature for a course as opposed to using a bibliography provided by faculty. Nurses are personally responsible for the cost and efficacy of the care they deliver. Hidden in this statement are the strategies that will enable us to claim our market share of the delivery system: attaching a dollar value to our service, aiming for data-driven decisions, measuring outcomes, and documenting and establishing ownership of our contribution. Nurses have traditionally been uncomfortable with this degree of objectivity. We have further fallen into habits of inadequate record-keeping and are shy about broader applications of information processing. Nurses stand at the center of the health care system. They are the logical brokers of information. Providers with the most information and the best information will move into positions of power and control. This imposes the need for curriculum attention to computer literacy. It is no secret that since the inception of DRGs, medical records has become the most powerful department in the hospital. Given this "information age" we live in, it is difficult to avoid becoming a content-laden curriculum. Adademic medicine and adademic law have compensated by using process as content. Beyond the basics, law and medicine place content in a case orientation and the focus of learning becomes problem-solving skills. The art of medical and legal education is cultivating a professional approach to problem identification and resolution. Beyond accepting process as content, a highly conceptual curriculum can allow the graduate to accommodate better to rapid change in any scientific field. It becomes difficult to reconcile these educational principles with an employment setting that expects a confident practitioner. The gap between the conceptual and concrete has to be bridged by case method, simulations of clinical management, and computer-assisted instruction. This gap is particUlarly wide and deep in regard to bioinstrumentation and medical devices. Educational programs have commonly minimized any obligation to develop technological competence in their graduates. Many nurses never rise above an initial discomfort and become controlled by technology. 64 These circumstances have given rise to the creation of new disciplines such as bioengineers and a host of technicians. Problems with practice encroachment follow closely behind. They grow as technology leaves intensive care and finds its way into the acute care unit, the nursing home and community. A relevant curriculum for the eighties includes a heavy dose of physics, equipment operating principles, frequent user errors, patient adverse reactions, common reasons for mechanical failure, and emergency operations. A health care environment that has been honestly described as complex, . unsettled, and, to some degree, hostile demands nurses who are assertive, strong in their practice, and steadfast in their convictions. Pioneers of this sort are necessary to salvage deteriorating and eroding markets for nursing, and to develop new markets. Personality testing to pre-select or counsel students in their occupational choices may be in the best interests of both the profession and the individual. Much of nursing's current inability to capture more power and prestige is a direct result of a reluctance to accept expanded responsibility and a distaste for assertive action and unpleasantness. It should be noted that nurses still have an exceptionally positive image with the consumer. In a recent public opinion survey, consumers saw nurses as the most logical group to help curtail health care costs by expanding their usual activities. Consumers thought that nurses should be able to perform physical examinations and prescribe medications. (American Nurses' Association, July l985) It seems that the only people who have reservations about nurses are nurses themselves. In today's times, when professionals in all categories have lost much of the respect once accorded by society, nurses have maintained a good image; we should take steps to capitalize on that situation immediately. Anyone who scans the press knows that we may soon lose this consumer edge. Articles in magazines and newspapers not uncommonly attribute hospital fatalities and inadequate health care to the absence of seasoned and experienced nurses. (New Yorker, June 22, 1987) Reports like these will begin to chip away at the good reputation of the profession. It remains to be seen whether nursing will fare better if candidates to the field are selected for their risk-taking capacity and interpersonal effectiveness. Acceptance of the responsibilities described in this paper demand the qualities of a professional. That being the case, socialization into the role may be the single most important goal of education. The more established professions 65 have layered concentrated study of the discipline on the base of a liberal education. A similar pre-professional course of studies rich in the natural and behavior sciences and the humanities may provide the best preparation for the intense study of nursing. Emersion in professional studies to the exclusion of elective and supportive courses may facilitate the development of professional identity. Law and medicine have been successful in developing identity, self-esteem and colleagueship. The nature and length of the pre-professional sequence holds both educational and political impliCations. The pre-professional requirement could be two years, or an associate degree or the baccalaureate with a masters degree as the educational credential for entry into professional practice. This approach is presented here to be debated. The restructuring of health care may ultimately require fewer, but more sophisticated nurses. The process of socialization into role is closely associated with the transition to practice which the student inevitably faces. The pain and disillusionment that frequently accompany this transition are well known. Nursing has made little allowance for the insecurity of the new graduate. Creative approaches to easing the transition from student to professional should be formally endorsed by nursing education. Work-study programs create a comfort with practice, assuming that the work is nursing. Academically endorsed placement of students with affiliate agencies for summer work and part-time employment during the school year are other options. Post-graduate residencies or extern- ships as part of the educational program should also be a consideration. Such arrangements require many decisions. Should they be mandatory or permissive, who should control the program-education or service,and should participants be compensated? Summary and Conclusions Health care in the eighties invites nurses to assume a more vigorous and visible leadership role. Health care has become more complex, and service gaps exist that compromise cost-efficiency. Nurses are uniquely suited to fix what is wrong by applying their talents in integrating, coordinating. developing human resources, and advocating for the client. Middle management skills, a research attitude, the ability to create and process information and comfort with advanced technology will allow nursing to claim its market share of the delivery system. TheSe are opportunities which could attract "the brightest and the best" into nursing. 66 The entry level curriculum should establish the ethos of personal accountability for one's own practice, for the practice of ancillary personnel, and in the broadest sense for the practice of one's colleagues. Conscious acceptance of this responsibility will bring nurses one step closer to controlling the practice environment as opposed to being controlled by it. Loss of control can be a response to being overwhelmed. Rapidly expanding technology and the limited shelf-life of knowledge are a challenge to all the applied sciences. A course of studies should consist of content that is selective, conceptual, and process oriented. Educators must resist the temptation to "teach it all.“ Clinical material should rarely be used for its own sake, but as a vehicle to develop the cognitive processes which characterize the professional. The challenges detailed in this paper demand professional practice while recognizing that an assisting role also exists. It is critical to move on nursing“: educational agenda of the past two decades. The times demand that organized nursing rise above internal politics to upgrade practice and standardize educatieall requirements for entry into the field. 67 References Aiken, Linda H. and Connie Flynt Mullinix. (1987). The nursing shortage. The New England Journal of Medicine, 317 (10), 641-645. American Nurses'Association. (1984). ANA's Concerns Reuardin the Im act of the Prospective Financing Mechanisms on Nursing Service. EMA/AMA Joint Meeting. Kansas City, Missouri: ANA. American Nurses'Association. (1987). Introduction of Community Nursing Organizations Legislation. Washington D.C.: ANA American Nurses' Association.(1985). National Public Opinion Survey on Nursing. Kansas City, Missouri: ANA. DeMaio, Dorothy. (1979). Born again nurse. Nursing Outlook, 27 (4). Joel, Lucille. (1985). Nursing's Role in the Changing Health Scene. Seattle, Washington: University of Washington School of Nursing. Joel, Luci11e. (1987). Reshaping nursing practice. American Journal of Nursing, 81 (6), 793-795. Johnson, Carol. (1985). Center for Research, American Nurses' Association, ‘ Kansas City, Missouri. Personal communication. Lang, Norma. (1987). Keynote Address, Annenberg Conference on Nursing in the 21st Century. Palm Springs, California. Mid-Atlantic Regional Nursing Association. (1987). Surve of Curriculum Adaptations in Response to the DRG System. Unpub1ished data: MARNA. Naisbitt, John & Aburdene, Patricia. (1985). Reinventing the Corporation. New York: Warner Books, Inc. New Jersey Department of Health. (1984). Hospital Management Reports. Trenton, N.J.: New Jersey Department of Health. New Jersey Health Care Administration Board. (1987). Minutes of Public Meeting, Hightstown, N.J.: N.J. HCAB. New Jersey Home Health Assembly. (1987). 1985 Home Health Data. Princeton: NJHHA. New Jersey State Nurses‘ Association. (1987). Quality Health Care in New Jersey ...The Nurses' Persepctive. Trenton, N.J. New York hospital on the spot. (1987). The New York Magazine, 40-47. Patterson, Joanne. (1987). Maximizing RN potential in a long term care setting. Geriatric Nursing.§_(3), 142-144. 68 Pinchot, Gifford. (1985). Intraoreneuring. New York: Harper & Row Pubiishers Rutgers Coiiege of NurSing, Teaching Nursing Home Project. (1987). Fina] Report (unpubiished). Newark. N.J.: Rutgers Coiiege of Nursing. Rutigiiano, Anthony J. (1985). Surgery on health care costs. Management Review, §§ (10), 25-32. Senate Committee on Aging. (1986). The Crisis in Home Heaith Care: Greater Need, Less Care. Washington, D.C.: U.S. Senate. 69 APPENDIX A 70 MID-ATLANTIC REGIONAL NURSING ASSOCIATION INVITATIONAL CONFERENCE THE IMPACT OF DRGs ON CLINICAL NURSING NEW YORK. N.Y. OCTOBER 19-20. 1987 P a r t i c i p a n t s Beatrice Adderly-Kelly, Ph.D., R.N. Assistant Dean for Undergraduate Programs College of Nursing Howard University Hashington,D.C.20059 Virginia Coombs, R.N., M.S.N., J.D. Executive Director Delaware County Home Health Services I lSth Street and Upland Avenue Upland. Chester, PA l9013 Anthony Disser, M.S., R.N. Vice President for Nursing Services United Health Services Johnson City, N.Y. 13790 Marilyn D. Harris, M.S.N., R.N._ , Executive Director Visiting Nurse Association of Eastern Montgomery County Abington, PA lQOOl-Ol9l Rose M. Hauer, M.A.,.R.N. Vice President for Nursing Dean. Phillips Beth Israel School of Nursing New York. N.Y. 10003 Lucille A. Joel, Ed.D., R.N. Chairman. Department of Adults and the Aged College of Nursing Rutgers, The State University of New Jersey Newark. N.J. 07102 Joyce Johnson, D.N.Sc., R.N. Associate Administrator Nursing Affairs The Hashington Hospital Center Hashington, D.C. 20010 Kathleen M. Maher. M.S.N., R.N. Director, Ann May School Jersey Shore Medical Center Neptune. N.J. 07753 Donna Maraldo, N.B.A., R.N. Director of Health Services Visiting Nurse Association of Delaware Nilmington, DE. l9085 Geri Moon, N.A., R.N. Assistant Director Professional Practice and Quality Assurance New Jersey Hospital Association Princeton. N.J. 08543-0001 Anita B. Ogden, Ph.D.,_R.N. Chairperson Division of Nurse Education Corning Community College Corning, N.Y. 14830 Joan O'Leary, Ed.D., R.N. Associate Professor and Key Advisor to Graduate Program Nursing Service Administration College of Nursing Villanova University Villanova, PA 19085 Franklin A. Shaffer, Ed.D., R.N. Deputy Director National League for Nursing New York, N.Y. l00l9 Health Resources and Services Administration Mary S. Hill. Ph.0., R.N. Chief Nursing Education Branch Participants - DRGs Conference, October 19-20, 1987, New York City ............... Mary S. Hill, Ph.D., R.N. (Cont'd.) Division of Nursing Bureau of Health Professions, HRSA Parklawn Building, Room 5C-26 5600 Fishers Lane Rockville, MD.20857 Staff Shirley H. Fondiller, Ed.D., R.N. Executive Director Mid-Atlantic Regional Nursing Association Ten Columbus Circle, 24th Floor New York, N.Y. lOOl9 72 MID-ATLANTIC REGIONAL NURSING WWW INVITATIONAL ODNFERENCE, «HUBER 19-20, 1987 The Impact of DRGs on Clinical Nursmg Care V15 a V15 Educational Institutions, Hospitals, and Camunity Health Agencies in the Mid-Atlantic Region. WW WWB&C AGENDA Presidifl' : Franklin Shaffer, Chairperson 1. Call to Order 2. Ammnoenents and Introductions ,3. Conference Purpose and Ebcpectations 4. Ivonograph Presentations a. Overview/Obsenratims b. Finflngs of Exploration c. Inplications for Educational Institutions, Hospitals, and Cannmity Health Agencies 5. Work Gruzp Discussion Sessions a. Identifying the relevant issues b. Detenrum‘n; curriculum inplications c. Ebcploring potential strategies 6. lhports and Rewmendations of Work Group Sessions 7. Summary, Conclusions, and Future Direction 8 . Adjounmant SHF:ji 9/29/87 73 APPENDIX B 74 MID-ATLANTIC REGIONAL NURSING ASSOCIATION BIBLIUERAPHY Auerbach, Marty (I985). Changes in home health delivery, Nursing Outlook, §§(6): 290-29l, November/December. The director of long-term home care, Home Health Agency Assembly of New Jersey acknowledges the changes occurring in home care created by DRGs, but believes the effects of the agents are difficult to isolate. She cites the newer demands in home care that require longer hours of professional nursing service and added supportive assistance from home health aides. Also noted are the implications for educators because of the changing health care environment. Further research is advocated to understand more fully the changes Cost Containment Legislation Passes. The Pennsylvania Nurse, g§(8): 3 August l987. The Pennsylvania legislature has passed a bill creating a Zl-nember state council to collect and analyze data from hospitals and other health care facilities. Significance of the bill is that state officials as well as health care providers, including nurses, will have data to plan and evaluate nursing care. A Nursing as yet, however, has no representation on the council and will need to monitor its work and find ways to be included in potential studies. Davies, Robert H., Hestfall, George, et al (l983). Reimbursement under DRGs: implementation in New Jersey. Health Services Research, l§(2), Part 1, Summer, pp. 233-247. _ The article addresses the issue of incorporating DRGs into health care reimbursement systems. Covering the period l978-l982, it details the problems encountered in implementing a ORG-based hospital reimbursement system in New Jersey. Explored is each phase undertaken in the process ofcrmducting a case-mix reimbursement system. Several concerns are discussed, such as, patient data requirements, financial and statistical data requirements, allocation of costs to patients, development of prospective rates, mechanics of payment, and present developments in New Jersey. Hsiao. Hilliam C.. Sapolsky, Harvey, M., Dunn, Daniel L., and Heiner, Sanford L. (1986). Lessons of the New Jersey DRG payment system, Health Affairs, §(2): 32, Sumner. The authors report for the first time on the initial phase of an extensive evaluation of New Jersey's experience with the reimbursement of hospitals based on DRGs. They begin with the origins of reimbursement reform, noting 75 New Jersey's long history of regulated hospital payment rates. Not until 1980 did it adopt the ORG-based all payer system in which hospitals were phased into over the next three years. Assessed is the impact of the system on hospitals and the reasons for an erosion of the expected cost containment features of ORG-based prospective reimbursement. Included are: the political realities of regulation, the constraints imposed on hospital administrators and the limitations of DRGs as a tool to monitor clinical practice. Morone, James A.. and Dunham, Andrew B (1986). Slouching toward national health insurance: The unanticipated politics of DRGs, Bulletin N.Y. Academy of Medicine, §§(6): 646-662, July-August. The authors incisively examine the political ramifications that have oCcurred with the introduction of reforms in hospital financing. They begin with the politics of hospital rate regulation in New Jersey and assess its development from a weak hospital system to one dominated by government using the DRG system. Covered are such issues as the politics of Medicare and the "new" national health inSurance, with a prediction that the latter may be on the horizon and without much fuss being made about it. Morrison. Pearle G., and Caterinicchio. Paul (l980). Case mix project, New Jersey Nurse, lQ(5): l, 7, l0, September/October. The participation of nursing service personnel in New Jersey DRGs implementation has contributed widely to pioneering efforts in Prospective Payment System. Throughout the state. nurses from selected hospitals were an integral part of a project aiming to provide a new and equitable method for determining nursing care costs to patients. This article describes the scope of the project, the studies involved, and the progress to date. A major contribution was the development of a nationally recognized tool, Nursing Diagnosis, for use in a nursing care plan. The instrument became a mechanism for furthering communication and ensuring quality of care on an individualized basis. Officials and staff of the New Jersey Nurses Association, as well as state nursing experts, have been participants in this ongoing effort. New York State Long Term Care Case Mix Reimbursement Projects, New York State Department of Health and Rensselaer Polytechnic Institute. Executive Summary: Derivation of RUG II, December l984, p. l2. This report summarizes the accomplishments made in the first year of a three-year funded project to develop case mix measures and a prospective reimbursement system for long-term care in New York State. After several alternatives, Case Mix staff developed a new classification system conprised of five major groupings. Also reported on were future steps to be taken over the next several months to work on the Medicaid case mix reimbursement system for implementation in the l986 rate year. 76 Taylor, Marietta (l985). The effect of DRGs on home health care, Nursing Outlook §§(6): 288-289, November/December. This article indicates that New Jersey's experience with DRGs has increased the need for home care for more acutely ill patients. Suggested is a case-and-control longitudinal study of hospital discharges and home health admissions to determine more conclusively the effect of the DRGs system on home care. The New Jersey DRG experience: success or failure? Cost Containment Newsletter, Special Report, l984, pp. 3-6. An assessment of the DRG system in New Jersey is discussed with caution given to making premature judgments. The burden will be on state health policy officia s to develop a reasonable schedule of rates so as to facilitate successful containment of costs. Differences are shOwn between the New Jersey DRG experience and the national picture. Wolf, Gail, Lesie, Linda K., and Leak, Allison, G. (l986). Primary nursing - the impact on nursing costs within DRGs, JONA 16(3): 9-ll, March. Conducted in Pennsylvania, this study compares direct nursing care costs within specific DRGs between a primary nursing unit and a team nursing unit. Data were collected through a computerized information system which recorded length of stay, acuity, and nursing care costs. Findings showed that despite an increased acuity of 28 percent, the primary nursing unit's average daily cost per patient per DRG was $l.30 less than that of the team unit. 77 “0V 14 1988 mi. BERKELEY LlanAnIEs . \IIIIIIIIIIII 1 cunuaqauaa ,