Should your home health agency offer special psychiatric services?
Should your home health agency offer special psychiatric services?
Mental health programs may make for healthy business
As administrators in home health agencies across the nation ask themselves how they will survive the effects of the interim payment system (IPS) and prospective payment system, some have found answers with specialty services.
Pediatric (see Hospital Home Health, March 1999, p. 25) and rehabilitative services are among those being offered by agencies looking to establish a name for themselves as their area’s leading home care provider. Still another area is psychiatric home health care services, which for some has proven quite fruitful.
Laura Elliott, MS, vice president of North Mississippi Health Services Home Health in Tupelo, has seen her agency’s program grow dramatically in the three years since it was begun. "We started with one psychiatric nurse, and today we have 11 who are dedicated to just psychiatric services. Our nurses average five visits a day, and we’re doing an average of 650 psychiatric-related visits a month," she says, adding that from her experience, it’s an area for which there is greater need than most people realize.
What has become a lucrative niche for Elliott is not without its challenges. Yet for those with the know-how and wherewithal to overcome these hurdles, mental health might prove a means of keeping an agency in the black.
Looking before you leap
As with any new venture, experts advise careful market research, and psychiatric home care requires no less. Among the factors to be examined include the community’s need for such services, the presence of a referral base, the availability of trained psychiatric nurses, and Medicare and Medicaid reimbursement policies.
While much can be gleaned from handbooks and the like, Suzanne Ward, RN, BSM, MSNC, psychiatric case manager for Longview, TX-based Good Shepherd Home Health Care, encourages interested agencies to go to a consultant. If that’s not an option, she advises that, at the very least, an agency contact a larger home health agency that has been offering a psychiatric program for at least two to three years because that’s about the time it takes to get a program running smoothly.
Other very important sources of information can be found locally. Area psychiatrists and those active in community mental health programs are excellent people to tap for ideas and information. In doing so, she notes, not only are you introducing yourself and your agency to potential referral sources, but you can learn what subspecialties are needed.
"Mental health agencies don’t want you doing their jobs, so we [home health agencies] need to find a place where we can make a difference," explains Judith Dodier, MS, RN, director of patient care services for Southern Vermont Home Health in Brattleboro. That has proven to be a place where people of all ages, who are homebound temporarily or unable to get to a treatment facility, can receive psychiatric services, she says.
Wanted: Qualified psychiatric nurses
A primary consideration before starting a mental health program, says Ward, is that "mental health patients have medical needs too. Our psychiatric patients receive occupational therapy and, occasionally, physical therapy — depending on the ailment. So for an agency to be cost-effective, it needs to start out with psychiatric nurses who specialize in mental health but who can fill in and handle medical patients as needed."
Finding such a nurse — or even just finding a qualified psychiatric nurse willing to work in home care — is perhaps the single largest challenge in running a successful mental health program. (See box , p. 63.)
The Health Care Financing Administration requires psychiatric nurses with two-year degrees to have at least two years of recent (within the past 14 years, says Dodier) psychiatric experience working in an acute psychiatric setting.
And in addition, says Elliott, "they need to be certified in psychiatric/mental health nursing, which requires that they maintain 30 contact hours a year or 150 hours over five years in that specialty area."
Current guidelines don’t require nurses with master’s degrees in psychiatric nursing to have two years of working experience. Those with bachelor’s degrees only need one year of hands-on experience, says Ward, but "there is something in the legislature now that would require American Nursing Association certification so everyone would need to have at least a bachelor’s degree."
Such expertise brings with it a higher salary than that paid to the average home health care nurse, and frequently, even those psychiatric nurses who do enter the home health profession soon move on to greener pastures, says Dodier, making a fledgling psychiatric program a potentially costly venture.
The staffing dilemma, notes Ward, is even more difficult in rural areas (often the very ones in greatest need of home mental health programs) because of a lack of psychiatric hospitals where potential home health nurses can get practical experience.
Adequately training aides
Just as psychiatric nurses need training in home health care, explains Elliott, home health staff require mental health education. "Many times aides have a lack of understanding of mental illness, and a patient’s behavior is then either misunderstood or misinterpreted. So we have our aides specialize as well and linked with psychiatric nurses. We’ve found this has increased patient satisfaction and patient care because our aides are educated as far as the patients’ diagnoses."
North Mississippi has taken training even further. "To make sure we have credentialed nurses, we do four to six weeks of intensive training visits where new psychiatric nurses accompany others to the home," Elliott says.
"We’ve developed a psychiatric nursing manual and require that all of our psych nurses go through 40 hours of lecture time and take a competency exam," she continues, noting that all the course work was developed in-house. "We have also developed eight teaching guides that are geared to the sixth-grade level that nurses can use with patients, as well as five care guides that help steer nurses through care on the top five referral diagnoses."
Assuming you have access to qualified nurses, garnering enough referrals can pose a daunting task. The bulk of an agency’s patients will still come from hospitals and inpatient facilities, says Dodier, but increasingly more are coming from general practitioners who have begun prescribing psychotropic medications.
"It’s even more important that there be better oversight in these instances," she says, "because you have people providing medication who are less familiar with it."
Community mental health programs are also good referral sources, Ward notes. "Especially now with their budgets being cut, if they can free up some of their money and give some cases to home care, then why not?" she says. "I know of some agencies who have contracts with their community mental health programs."
She cautions agencies not to rely on psychiatrists’ referrals alone, although she does advise administrators to make personal visits to area psychiatrists to introduce themselves and their facilities. Moreover, Ward believes in educating a community about mental health issues and an agency’s services.
"Put together some pamphlets or write letters to local mental health groups, but, above all, you have to advertise and market yourself," she says. "People just don’t know what it [psychiatric home care] is and the possibilities it can apply to."
Develop new positions
To ease its entrance into mental health services, notes Elliott, North Mississippi developed two staff positions dedicated to this burgeoning niche. "We have a separate medical director just for our psychiatric program, and this has proven helpful in assisting with patient care issues as well as multidisciplinary team meetings and staff education, policy, and procedures. He has really helped define the guidelines for the program.
"We also have a psychiatric liaison who acts as a link between the physicians, mental health services, and the hospital in helping them to identify what patients you see and how they can help. It’s really a means of educating the medical arena in mental health services," she concludes.
Medicare and Medicaid are the primary reimbursement sources for psychiatric home care services. "It takes an act of Congress to get a private insurer to pay," says Dodier. So agencies face the same reimbursement issues as with other services. In other words, she adds, "They never cover all your costs."
Even so, there are ways to make mental health services cost-effective. If a psychiatric nurse temporarily finds herself with a small caseload, she can fill in with medical visits.
Then, too, says Ward, "Even preferred providers will look at the statistics and see [psychiatric home health] is much less expensive than sending someone to a therapist for $100 an hour."
Elliott quotes several benchmarking studies North Mississippi has conducted in noting that "psychiatric home care is cost-effective because it decreases the number of hospital stays. Because nurses see problems sooner and contact the doctor, it can prevent long hospital stays and help and improve with medication compliance."
The need to overcome the barriers
In spite of the obstacles, Dodier, Ward, and Elliott all agree that there is a need for and opportunities available in the area of psychiatric home care, especially in the area of subspecialties.
Dodier’s agency, for example, offers a prenatal program for low-income obstetric patients. For those with psychiatric disorders, "we offer unlimited home visits where the maternal and psychiatric nurse can see the mother," she says.
Ward, in noting that Medicaid doesn’t approve psychiatric nursing "for young people," says she has worked with those who have recently undergone an amputation and are grieving or elderly patients mourning a recently deceased spouse. Common to all programs are patients with depression (oftentimes elderly women), dementia with delusions, schizophrenia, Alzheimer’s, and neurological problems.
Elliott believes agencies can find respite from the effects of IPS with mental health programs as the reimbursement system moves to "a certain dollar amount per episode. Nurses that are strong in a particular area will have better outcomes in a shorter period of time." And that is where savings will be realized.
Sources
• Judith Dodier, MS, RN, Director of Patient Services, Southern Vermont Home Health, 3 Holstein Place, Brattleboro, VT 05301. Telephone: (802) 257-4390.
• Laura Elliott, MS, Vice President, North Mississippi Health Services Home Health, 600 W. Main St., Tupelo, MS 38801. Telephone: (601) 791-2499.
• Suzanne Ward, RN, BSM, MSNC, Psychiatric Case Manager, Good Shepherd Home Health Care, 103 W. Loop 281, Suite 470, Longview, TX 75605. Telephone: (903) 236-2641.
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