Directors look to UAPs to enhance care plans

Set clearly defined roles to make UAPs an asset

Despite the controversy surrounding the improper use of unlicensed assistive personnel (UAPs) in some home care agencies, UAPs have a legitimate role to play in helping agencies save money and allowing nurses more time to focus on the clinical aspects of their jobs. However, directors must know the pitfalls of using UAPs.

What’s needed is a keen awareness of your state hiring laws for UAPs, and a way to set up clearly defined roles and responsibilities based on those laws, experts say. In some states, for example, criminal action may be taken against an aide, or the aide’s employing agency, if the aide performs a simple gesture like filling a patient’s "med minder" with pills or applying an antibiotic cream. These acts are considered dispensing a medication, and an agency could lose its license or its Joint Commission accreditation.

While UAPs have always been instrumental in the delivery of home care, their roles often become blurred with those of their clinical counterparts in agencies’ attempts to save money.

"Typically, the cost difference is between $13 an hour for a registered nurse and $7 an hour for a UAP," observes LuRae Ahrendt, RN, CRRN, CCM, a nurse consultant with Ahrendt Rehab in Norcross, GA, whose agency works with home health agencies to provide case management services for children and adults with catastrophic injuries. Yet, allowing UAPs to dispense medications, give tube feedings, catheterize, and make decisions and assessments about patients’ levels of care is a dire misuse of this type of personnel, explains Ahrendt.

However, a solid plan that includes the proper use of UAPs will allow home care nurses to focus more on the clinical aspects of their patients’ care, while the UAP can oversee the nonclinical aspects, such as helping an unstable patient from the bed to the bathroom to prevent a fall or simply retrieving medications, say agency directors who are using UAPs.

John Templin Jr., CHC, FACHE, president of Templin Management Company, a Greenfield Center, NY-based health care company that works with home health agencies to improve productivity, agrees with Ahrendt that agencies’ efforts to reduce costs are spurring the use of more UAPs in home care.

"Agencies have limited dollars that they are being paid by whoever is reimbursing them for their services, and that’s what is driving this trend toward using more UAPs," observes Templin. "Agencies are saying, ‘If we’re getting X dollars per visit, then how do we get the biggest bang for that visit? If the patient has multiple needs, to what extent can an employee, either licensed or unlicensed, meet those needs, which can include specific interventions, treatments, monitoring of medications, and obtaining laboratory specimens?"

Interim Health Care Services in Tucson, AZ, is one agency in which UAPs work closely with nurses and directors. While the agency has been careful to develop thoughtful job descriptions clearly defining the UAP role, Faith Barry, senior director of branch operations, understands how easily some agencies can fall into the cost-cutting trap. "I can see where agencies that do not have strict supervisory standards or have not clearly defined what the [UAP] role is can fall into a trap because they’re trying to save money," says Barry.

"It costs us money to have nurses on call for just those one or two calls during the week where we might need a clinical person. They’re paid whether they’re used or not. That’s expensive, but if it were my mother needing the care, I wouldn’t want a UAP dealing with her high blood pressure," says Barry.

However, all sources admit that UAPs definitely have their place in the realm of home health services. "In some situations, a lot of care can be provided by unlicensed personnel, such as performing unsterile dressing changes or pouring medications out of a bottle for a quadriplegic whose cognizance is intact," says Ahrendt. "In such cases, [UAPs] are making no choices, no assessments, no decisions — they are just being the patient’s hands."

Using UAPs to your best advantage

With such growing scrutiny on the proper use of UAPs, directors have become more careful in devising strategies to use UAPs in their home care plans.

For example, directors at Intermountain Health Care (IHC) in Salt Lake City have been using UAPs as "sleepers," in their terminology. This staff typically comprises college students who stay with patients overnight.

The sleepers essentially "sleep at a client’s home during the night simply because the family needs an extra person for security and safety reasons," explains Sherry Smith, RN, nursing manager. If the patient wants to get out of bed during the night, he rings a bell, placed at his bedside by the sleeper, and the sleeper gets up and goes with him to the bathroom or wherever he needs to go.

The biggest benefit the agency has derived from the program is a reduction in patient falls. "We were finding that some of our patients were having falls mainly at night when they were alone," she recalls.

"We’ve seen a significant decrease in the number of falls our patients were experiencing by simply having someone there to get up with them." Although Smith was unable to put a number on that reduction, she said the agency had one patient who fell two or three times every month, but when a sleeper began staying with her, her falls were reduced to zero.

Should a patient need medical attention during the night, the sleepers call one of the on-call directors.

Smith often recruits for the sleeper position through current and former patients. "We’ve recruited many sleepers whom we have gotten to know because we’ve taken care of one of their family members," says Smith, adding that background checks are conducted on all candidates.

"We’re looking for young people who are really stable, have good grades, and are social, so we check references very carefully," continues Smith, who employs between six and eight sleepers at any given time. (See related story on recruiting UAPs, p. 113.)

The sleepers typically earn between $7 and $9 per hour and work a set schedule three to four nights per week. They also rotate through the weekends, so they’re not working every weekend.

Smith continues that the directors’ reaction to using UAPs in this capacity has been "very positive because they don’t have to worry about their patients at night. Home health nurses tend to get involved with their families. These are people they care about, so if the sleepers can stop any accident or increase the safety, it relieves their stress."

Client Service Representatives (CSRs) round out the realm of professionals who help manage cases in various capacities at Interim, explains Barry.

Nonclinical staff handle scheduling

"We have a clinical person and nonclinical person on call at all times," says Barry. The nonclinical staff are trained customer service people. An on-call CSR staff member may be trying to replace a worker who has called in sick, as opposed to dealing with clinical emergencies, explains Barry.

"The on-call clinical person is essentially on call to assist the CSR if there is a clinical need. This way the CSR doesn’t make clinical judgments, but because she [the CSR] can do scheduling, the case manager has more free time to deal with the clinical issues," Barry continues.

"If a patient needs to be seen in the evening or on the weekend, then the case manager on call is free to do that without the worry of carrying a phone if, for example, a scheduling issue needs to be addressed at the same time. They are devoted strictly to the clinical areas, since that’s their expertise."

Barry’s office employs between five and six CSRs at any given time. The typical pay range for this type of UAP is between $7 and $9 per hour.

Most CSRs work assigned hours, but there are staff who prefer strictly on-call work and may come into the office during office hours to supplement their hours. "We have one woman whose lifestyle and family needs are such that she primarily works on call, and she doesn’t come into the office unless someone else is sick," explains Barry. "She may come in one day per week for a couple weeks in a row. Another CSR has a fairly regular schedule of a couple days in the office and then time on the weekends and evenings on-call.

"The other CSR staff are assigned to the office during the week day, including a client service manager who supervises the client service staff."