Guest Columns

Advice on primary permanent nursing

Ellen Rychlik
Ellen Rychlik

There is several benefits to considering an Acuity Based Primary Permanent Nursing Assignment in your efforts to attract acute and managed care providers. Several questions were raised during the McKnight's Online Expo presentation that I would like to touch on briefly. You can also listen to a re-taped version of the Expo On Demand by clicking here.

The model looks at seven different factors determining the time at the bedside: Number/complexity of medication administration, complexity of procedures, patient education, psychosocial issues, intravenous therapy needs, infection prevention protocols/needs, and ADL's.  Acuity assessments are done regularly so adjustments can be made in order to align the needs of the patients with the necessary nursing staff. Nurses help to decrease lengths of stay, prevent illness, errors, complications and hospital readmissions, all of which saves money for providers and health plans and adds to overall productivity.

The model recognizes and supports the long-term financial benefit that good nurse staffing and supportive working environments can offer by avoiding complications, improving quality performance, and reducing hospital readmissions.

Patients entering into the healthcare setting are generally frailer and have more extensive and complicated care needs related to the higher acuity and clinical instability at point of hospital discharge in addition to the multiple co-morbidities, age related functional and physical changes, and family, social, and behavioral characteristics. In short, they not only have different care needs than the majority of patients had in the 1980's and 1990's (when the current care models were developed), but those care needs are best met by different staffing models that take advantage of roles of “professional” providers.

Little research focuses specifically on nurse staffing in nursing homes, in part because nursing homes generally employ large numbers of nurse's aides and comparatively fewer RN's and LPN's…..impossible in today's environment.

With the industry goal of taking on the higher acuity, there needs to be a restructuring of priorities, staffing models and care delivery systems. The delivery of safe, effective/efficient, quality care to the patient with the desired reduction in re-hospitalization is insurmountable while employing a 1980's nursing home philosophy as it pertains to staffing models and staff skill level. Reimbursement needs to fall in line with the higher complexity acute clinical care being provided in the sub-acute/nursing home setting.

Elderwood at Hamburg is a 166-bed post-acute and long term care facility located in a rural area. Forty-six beds are designated to the post-surgical, medically complex, oncological care and rehabilitation patient. We have developed an acuity-based staffing model that both safely meets the needs of the higher complexity patient and also serves as a venue in which to negotiate appropriate reimbursement rates for the high quality care delivery provided in lieu of the acute care setting. 

We have strived to develop systems, in that the forward-thinking healthcare leaders will recognize, for the long-term financial benefit that good nurse staffing and supportive working environments can offer by; avoiding complications, improving quality performance, and reducing hospital readmissions.

The Permanent Primary Care Nursing Model provides for a comprehensive, coordinated approach to patient/resident care with the best prepared, i.e. the licensed nurse rather than the least prepared in the most direct and constant care relationship with patients/residents and families. It is the continuity/consistency in the relationship with patients/residents and families that must be preserved if balance is to be struck between the cost and quality in healthcare.

With the complexity in resident acuity on the rise, the need for licensed professionals is essential. By placing the nurse back at the bedside in a holistic care approach it allows for identification of deviation from patient/resident baseline ensuring early intervention and prevention of acute exacerbation. 

The continuity of the care giver ensures predictability of routine allowing for the desired anticipation of individual patterns as they pertain to the activities of daily living and behavioral deviations. This in turn allows the staff to better meet the needs of the patient/resident population ensuring resident safety and behavioral and physical well-being.  The cost savings in the per diem rate, comparing the acute care setting vs. post-acute care, is significant.  The quality of care provided is consistent.  

The benefit(s) of embracing the intermediary care provider are extraordinary and the list is extensive.  The proposal of an evaluation for an abbreviated acute care stay with an accompanying intermediary stay will ensure for both clinically and financially desirable patient outcomes.  The patient is provided the same high quality services at a lower level of care which better prepares the patient for discharge to the community and prevent re-hospitalizations. 

Our SMARTS program does take patients directly from the PMD, home care agencies, immediate care providers and the emergency department. The population considered are those patients with managed/private insurance plans.

Ellen Rychlik, RN, BSN, is the Director of Nursing at Elderwood at Hamburg.

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