Transcript Department of Health and Senior Services

New Jersey Nurse
Delegation Pilot
Program
William A. B. Ditto
Director
Division of Disability Services
New Jersey Department of Human Services
Overview of Presentation
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Why Pursue Nurse Delegation in Home
Care?
What is the Status of Nurse Delegation in
NJ?
The Nurse Delegation Process
Design of the NJ Pilot Delegation Program:
“There’s No Place Like Home”
Some Early Findings
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Why Did NJ Pursue This?
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Demographics
Economics
Support to unpaid Family Caregivers
Better use of professional nursing personnel in
home care agencies
Patient Safety
Acknowledge home health aide skills & talents
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Why Did NJ Undertake this Project?
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Individuals are in nursing facilities who want to be
in the community or with family
Families find that home care aides cannot provide
the type of service they need to maintain loved
ones at home
There is a shortage of licensed nursing personnel
Demand for home care will escalate dramatically
as the “boomers” begin needing LTC services
It has been effective in other states
NJ must address its “Olmstead” obligation
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Why Did NJ Undertake this Project?
(continued)
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Family caregivers “burn out” or risk loss of
employment because of care giving and need to
perform “skilled tasks”
We are not making full use of the skills, knowledge
and talent of registered professional nurses who
work in the Medicaid PCA program
We know (but never acknowledge) that aides are
performing skilled tasks without nursing oversight
or supervision
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Nurse Delegation in New Jersey
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In New Jersey, after assessing a
consumer’s condition and the
competencies of unlicensed assistive
personnel, nurses may “delegate selected
nursing tasks” to unlicensed persons.
There are no specific restrictions on the
tasks that may be delegated, provided the
task does not require the knowledge and
judgment of a nurse .
Source: NJAC 13:37-6.2 – (State Board of Nursing Regulations)
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Restrictions on Delegation to
Certified Home Health Aides in NJ
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Current rules regarding certified home health
aides (CHHA) prohibit them from administering
medications (NJAC 13:37-14.3)
This prevents nurses from delegating this task to
CHHAs because the aide cannot accept the
delegation.
(Nurses can delegate this task to other Unlicensed
Assistive Personnel (UAP) at present in other
care environments, e.g.. hospital, assisted living
facility.)
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Exemption for Delegation in New
Jersey’s Pilot Granted
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The State Board of Nursing issued a letter of
support on October 22, 2008 allowing
medication administration by CHHA’S
within the parameters of the pilot to help
inform regulatory changes by the Board of
Nursing in the future.
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Delegation – Dealing with Issues
Issues that can be barriers to delegation:
Process of delegation—clarified in rule with forms
provided so that nurses know they have documented
needed items.
 Liability issues—language protecting nurses from
situations where aides do not follow their instructions.
 Authority of nurse only to delegate—nurses, rather than
their employers, retain the authority to decide where
delegation is appropriate.
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Pilot “Drivers”
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Home care agencies indicated that providing
“intermittent” skilled care several times a day by
licensed nurses is not practical or realistic in the
current environment
Skilled nursing care at home identified as a crucial
element for facilitating deinstitutionalization, by
NJ Olmstead Stakeholder Task Force (2001)
NJ had a federal “Real Choice Systems Change
Grant” and could use funds to explore Nurse
Delegation as an innovative practice
Consumers wanted to stay at home with care
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A Review of the Delegation Process
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PCA Pilot agency nurses, who have been oriented,
review new referrals and current caseloads and
determine which consumers would benefit from
delegated services
The decision to delegate or not and to rescind
delegation is the sole responsibility of the nurse based
on his/her professional judgment.
The RN uses triad model of delegation -- one nurse
delegates tasks to one aide for one consumer. Task
competency of the CHHA is not transferable from
one consumer to another, even if the nurse and aide
are the same for other consumers. Must be patient
specific. Each skilled task requires an individual
delegation.
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A Review of the Delegation Process
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The RN has the right to refuse to delegate tasks of
nursing care if he/she believes it would be unsafe or
inappropriate to delegate or he/she is unable to provide
adequate supervision.
Decisions relative the frequency of supervision and
reinforcement of the performance of delegated tasks is
the domain of the front line (delegating) nurse.
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Nurse Delegation Pilot
Research & Development Phase
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Series of Meetings & Forums with Board of
Nursing, Consumers, Home Care Agencies &
Associations, CHHAs and Insurance Carriers
Review of Similar Projects in Other States and
Research Findings
Under contract to the Division, Rutgers University
designed a model “pilot” program for Nurse
Delegation in NJ
Pilot Evaluation Component also was developed by
Rutgers University (Center for State Health Policy)
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Nurse Delegation Pilot
Study Population
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Study population consists of individuals eligible
for Medicaid personal care assistant (PCA)
services
Does not impact on (or negate) the receipt of any
other Medicaid services
Intended to address the needs of individuals with
relatively stable conditions who require ongoing
PCA service in the community
PCA recipients may have their authorized hours
increased when they enter delegation pilot to
account for aide training or expanded service
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NJ NURSE DELEGATION PILOT
Design Features
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Board of Nursing agreed to allow medication
administration by Certified Home Health Aides for
duration of the pilot
DDS/DHS selected 21 Home Care Companies
with 49 locations to participate in the pilot on a
voluntary basis
Target is to have 200-300 individuals who will
receive nurse delegated services over 2-3 year
period
Participation is VOLUNTARY for everyone
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NJ Nurse Delegation Pilot
Design Features (continued)
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Delegating nurses (and agency administrators)
have been oriented about the process of
delegation, using the State Board of Nursing
Delegation Algorithm
Agency field nurses identify potential participants
in their caseloads
The Division works with the Community Choice
Counselors, at the NJ Department of Health &
Senior Services, to identify individuals presently in
nursing facilities who could transition out if
delegated services are made available
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NJ Nurse Delegation Pilot
Design Features (continued)
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Home care agency’s delegating nurses have the
“final say” in all matters related to delegation
Participants, agencies and nurses are asked to
cooperate with researchers in both allowing
interviews and providing data.
A unique Medicaid PCA procedure code and rate
have been developed to cover the cost of the nurse
delegation service. As mentioned the recipients
authorized hours may be increased temporarily for
training or longer term because a new task has
been added for the aide (ongoing)
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Delegation for Participants Currently
in Nursing Facilities
 Department of Health & Senior Services (DHSS) staff
identify, with NF staff, potential candidates who wish to
live in the community and are appropriate for the Pilot
study during discharge planning sessions.
 Using the list of participating Pilot PCA agencies,
DHSS staff invite a local PCA agency to attend a
meeting with the potential participant, family and other
advocates to review the efficacy of delegation services
when discharged.
 Pilot staff have also conducted training sessions with
discharge planners in hospitals and nursing facilities to
make them aware of the expanded service.
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NJ Pilot Program Oversight
& Reporting
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An Advisory Council, made up of a cross section of
stakeholders, is in place to provide advice and assist
with problem solving. The Advisory Council meets 2-3
times per year. As the needs of the management team
change over the life of the pilot, so does the
membership of the Advisory Council.
Periodic updates are issued to keep the home care
industry, not involved in the pilot, informed of the
progress and outcomes of the pilot.
A bi-monthly report is being generated for the Board
of Nursing
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Funding
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The Division applied for and received multi-year
funding from the Robert Wood Johnson Foundation
(RWJF) to operate the pilot for a 36 month period.
RWJF funds are matched with Title XIX (Medicaid)
funding to provide adequate resources.
Discussions with the Assistant Secretary for Evaluation
& Planning (ASPE) at federal DHHS resulted in
additional funding being provided for the evaluation of
cost effectiveness by Mathematica Policy Research of
Princeton
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Some Early Findings in NJ
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21 Home Care companies participating with 44
sites
186 registered nurses completed the orientation
program
210 individual Medicaid clients have received
delegated services
150 patients are active in the program as of
February
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Some Early Findings in NJ
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Medication administration is the most requested
service (February 2010)
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132 medication administration delegations
106 Oral
 9 Injectable
 9 Topical
 6 Other Routes
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24 Blood Glucose Monitoring
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Some Early Findings in NJ
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Other Delegated Tasks (25)
Gastronomy Tube Feeds
 Catheterization, bladder & bowel programs
 Wound Care
 Insulin pre fill
 Cough assist
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Long Range Goals
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Add options for individuals to remain at home
& in the community or to leave a nursing facility.
Address the Olmstead decision mandates.
Inform changes in the State Board of Nursing
Regulations to support delegated medication
administration by home health aides.
Make better use of existing home care provider
agency services.
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For further information:
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Contact:
Susan Brennan McDermott, RN
Project Manager
NJ Nurse Delegation Pilot
609 292-1268
[email protected]
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