Be it friend or foe, managed care is gaining, and it’s rolling your way

Your staff will need inservices to get ready for the change

It’s coming. Da-dum, da-dum, da-dum. Like the scary cello music preceding the attack by the great white shark in the movie Jaws, managed care is swimming your way.

Experts advise education managers to be prepared. Managed care now insures 60% of the U.S. population, and it is quickly spreading to health care plans for the elderly and indigent.

Education managers could be on the cutting edge of easing the transition for home care agencies. You can prepare inservices that show nurses and other employees how to change their professional habits to meet managed care criteria.

"Basically, no matter what, we’re going to see changes in the health care arena," says Nancy Harvey, BSN, RN, senior consultant with Healthcare Concepts of Memphis, TN, which is a private home care consulting firm. It provides educational programs, publications, and executive searches.

Healthcare Concepts Vice President Jennifer Jenkins, MBA, RN, CNAA, predicts that most of the home care industry will evolve into managed care patterns within three years. "There’s more and more consolidation in the managed care market; it will reach into rural and urban areas," she insists.

So what can education managers do to get ready for the change?

Homecare Education Management has asked managed care experts for tips on teaching staff about the concept. (See Guidelines to Teaching Managed Care, p. 3.) They offer this advice:

1. Define managed care, and explain how it is different from Medicare.

Managed care companies contract with specific agencies on a bidding basis. The home care agency agrees to provide a certain level of care in exchange for a set amount of money. This can be in the form of payment called capitation.

"Basically, it is a set fee per patient per month to provide the total care of that patient," explains Linda Prima, RN, network director for Supra Management Corp. of Metairie, LA. The private company consults with home care agencies, providing educational programs and research.

"Agencies must know what their costs are, in order to enter the world of managed care," Prima adds.

New incentive to reduce visits

Medicare’s traditional method was to pay an agency a set fee per visit. The more services and visits an agency provided to a patient, the more money it would make. Under managed care, the more services an agency provides to a patient, the less money it will make.

The length of stay is shorter under managed care. While there will be a larger number of admissions than there have been under Medicare, there also will be a larger number of discharges, and the agency’s total number of home visits might decline.

"The biggest thing is that the Medicare program really does not put much of a limit on the number of home care visits," Jenkins says.

"As long as you stay within your cost cap — which is pretty generous — people would keep on seeing patients; there isn’t a real incentive to discharge patients from home care," Jenkins adds.

2. Explain what managed care companies mean by the term "outcome."

With managed care, agencies have to show an outcome, meaning they have to reach a point where the patient no longer needs home care services and still will not be re-hospitalized.

"You have to show more of the teaching or the actions you have taken with that patient to reach that goal in a shorter period of time," says Hope Jackson, MS, MPH, RNC, director of education for Supra Management Corp.

"Before we were trying to get the most out of a patient encounter, and now we’re trying to demonstrate that outcome, to get to the target quicker," Jackson adds.

Move toward patient self-care

Many nurses will have trouble understanding the outcomes goal because it was never emphasized in traditional home care, says Sharye Hardesty, MBA, BSN, RN, vice president of clinical services for Supra Management.

"Medicare pays for it as long as you provide a skill, and you may never be concerned that you provide the same skill for six months," Hardesty explains.

"It was not in the nurse’s interest to reach a specific outcome because if the patient reaches a desired outcome and doesn’t need a visit, then the nursing care is no longer needed, and the nurse must seek new patients in order to maintain a caseload."

That philosophy is out the window under managed care.

"The industry is demanding that more information be given to them in a shorter period of time," Jackson adds. "So we have to step back and say we’ve met these goals."

One way home care agencies do this is through documenting their teaching efforts and the patients’ responses to the teaching.

3. Show nurses how they can involve the families and patients to shift care responsibilities to them.

"Under the Medicare mentality, you could see patients [more often] to keep them out of the hospital, instead of being creative and involving the family more in the care," Prima says.

"If the family says, ‘I don’t want to be involved,’ they’d leave it at that," Prima adds. "But under managed care, we try to probe into the families’ fears to see why they don’t want to be involved, and then we attempt to eliminate those fears."

Nurses sometimes think their patients and the patients’ families will not be able to take care of their own wounds or injections. But experts say it’s a mistake to assume this because most people can learn how to handle simple procedures.

Teaching patients works most of the time

"We’ve had very few patients who have not been teachable in the home," Prima insists. "They may be frightened, but they do learn. And after they learn, they feel more in control of their health and their bodies."

Hardesty recalls the case last Christmas of an IV patient who was indigent, and the hospital discharged him into home care.

So the man went home with his IV. But about half of the time the nurse visited the man’s home, he wasn’t there, Hardesty continues.

"We thought the patient was too unstable to do his own IVs. But two days later, we caught up with the patient and his wife, and she said he infused himself and had continued with his own IV treatment," she concludes.

Prima encourages nurses to find creative solutions to what might first appear to be problems that only a home care visit can solve. For example, she says, a home care agency will automatically have a home health aide regularly visit to bathe a patient.

"Under managed care, they have to be more creative and look at the possibility of teaching the patient some rehabilitation methods to make bathing easier," she points out. Also, maybe a busy family member could bathe the patient in the evening after work.

Still, agencies can set their own standards and stand up to the demands made by managed care companies, one education manager says.

When teaching doesn’t work, document

"I always tell nurses to assess the skilled care, and if the conditions are unsafe they should tell the physician so we can re-assess the plan," says Donna Millet, RN, education instructor for Thibodaux Regional Medical Center of Thibodaux, LA. The 150-bed hospital has a home care agency with a staff of 40.

Millet recalls one case in which an insurance company wanted her to teach a patient how to do her own central line dressing change. Millet taught the patient’s husband how to flush the line, but she thought it would be unsafe to teach the patient the skill.

When this type of conflict occurs, Millet recommends nurses take the following actions:

• Bring the case back to the physician.

• State your case with patient safety in mind.

• Document all conversations.

• Send a report to the case manager, and include it on the patient’s chart.

• Wait for a response from the insurance company, and then make a decision about whether you can continue to provide that patient care.

Millet says that when she has turned down a case because of safety issues, she typically would say that the agency "couldn’t get enough visits, so we didn’t think we could take the case safely."

Another option, Prima suggests, is for the agency to use a partnering philosophy when dealing with case managers and managed care companies. This means the nurse provides the case manager with additional information, and the two work together to find alternatives.

"To date, our agency has not turned down or felt a necessity to turn down a case because of a disagreement with the number of visits authorized," Prima says.