f REPORT OF THE SOUTHERN REGIONAL EDUCATION BOARD IMPACT OF DRG 5 ON NURSING [”le » PW“ I US DEPARTMENT OF HEAIIH (2 HUMAN SIIWIUS PubIIC Heolrh Sen/Ice HeoITh Resources and SeNICPS AdmInIsIronm. PUL‘IHC HEALTH ll” 17' "RY HEALTH RESOURCES AND SERVICES ADMINISTRATION “HRSA—Helping Buiiid A Healthier Nation" The Health Resources and Services AdmInIstratIon Health Sewi . or health serv deyang resource Is- - I delivering and other groups; - Panicipa mg in the campaign against AIDS; 0 Sewing as a focal point for federal organ trans- plant activities; has leade‘ hip responSIbIIIty in the US PUblic t ed reSIdents mothers ‘mo toring their compete " 9 Operation of a nationwide data bank on malpractIce claims and sanctions; and -‘ Menitoring developments affecting health facil— ities especially those in rural areas. L IMPACT OF DRG'S ON NURSING- REPORT OF THE SOUTHERN REGIONAL EDUCATION BOARD”. US. DEPARTMENT OF HEALTH 6 HUMAN SERVICES Public Health Service Health Resources and Services Administration Bureau of Health Professions Division of Nursing A H.) . OEPOSTTQH ‘1 JUL 201988 This report was prepared under purchase order number HRSA 87—337(P) from the Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services. Division of Nursing Project Officer is Mary S. Hill, RN, PhD, Chief, Nursing Education Branch. This document is for sale by the National Technical Information Service, 5285 Port Royal Road, Springfield, VA 22161. Accession number: HRP—0907l8l. Issued: July 1988. ii FOREWORD {9?}; Cost containment efforts in the reimbursement of health facilities under 3’ y the prospective payment system have contributed to changes in the " responsibilities and role of the nurse providing clinical care to patients. However, accurate data have not been available to assess the impact these changes were making on nursing practice and the subsequent implications for undergraduate nursing education. In an effort to obtain the needed data the Division of Nursing undertook a major project with four regional professional nursing organizations. A panel of experts from each region met at an invitational conference to I) examine the impact that the implementation of diagnosis related groups in the reimbursement of hospitals and community settings has had on clincal nursing care in the region and, 2) to examine the implications of any changes for undergraduate nursing education, especially in the clinical area. The four regional reports, containing monographs submitted by leading nurse scholars within each region and the conclusions and recommendations of the panels, are presented in separate publications. They are available for purchase from the National Technical Information Service (5285 Port Royal Road, Springfield, Virginia 22161) under the following titles and accession numbers: Impact of DRGs on Nursing: Report of the Mid—Atlantic Regional Nursing Association (HEP-0907180) Impact of DRGs on Nursing: Report of the Midwest Alliance in Nursing, Inc. (HEP—0907178) Impact of DRGs on Nursing: Report of the Southern Regional Education Board (HEP-0907181) Impact of DRGs on Nursing: Report of the Western Institute of Nursing (HRP—0907l79) Through examining current clinical practice and proposing patterns for changes in nursing education, the work of the regional groups will have far reaching benefits for both users and providers of nursing care services. liott Division of Nursing 111 TABLE OF CONTENTS Overview Audrey F. Spector Conclusions and Recommendations Ruth Yurchuck Diagnosis Related Groups: Implications for Undergraduate Nursing Curricula Frances C. Henderson Report of a Survey of Undergraduate Nursing Schools in the South on the Impact of DRGs Eula Aiken The Impact of DRGs on Clinical Nursing Care in Tertiary Hospital Settings Barbara A. Donaho Report of a Survey on the Impact of the Prospective Payment System on Clinical Nursing in Hospitals in the South Shirley J. Carey The Impact of DRGs on Nursing Care in Community Settings Judith Baigis Smith Roster Authors, Panel of Experts, Staff Page vii 34 41 65 77 101 OVERVIEW On June 1, 1987, the Division of Nursing, Health Resources and Services Administration, Department of Health and Human Services, awarded $12,041 to the Southern Council on Collegiate Education for Nursing/Southern Regional Education Board for a six-month activity to provide "Information Concerning the Impact of the Prospective Payment System (DRGs) in the Reimbursement of Hospitals, on Clinical Nursing Care in Hospital and in Community Settings." Implications for modification of undergraduate clinical and didactic nursing undergraduate courses were to be identified. The region-specific information would be of value to nurses who practice in educational and service settings. The activity's major tasks were: 1. From within the South, three persons with the necessary expertise were identified and each agreed to prepare a monograph. Barbara A. Donaho (Vice President for Nursing and Patient Services, Shands Hospital, University of Florida) wrote on the impact of Diagnostic Related Groups (DRGs) on clinical nursing practice in hospitals. Dr. Judith Baigis Smith (Director, Long-Term Care and Health Promotion, School of Nursing, The Johns Hopkins University) wrote on the impact of DRGs on the clinical practice of nursing in community settings. Dr. Frances C. Henderson (Chairman, Baccalaureate Program, Division of Nursing, Alcorn State University) wrote on implications for undergraduate nursing education. vii 2. To gather additional information, SCCEN staff conducted a mail sample survey of undergraduate nursing education programs and hospitals in the South. The questionnaire used for both surveys was developed by Dr. Frank Shaffer (National League for Nursing staff) and used for this Southern survey with permission of Dr. Shirley Fondiller, Hid-Atlantic Regional Nursing Association staff. Dr. Shirley Carey (Emory University) handled the analysis of data from the hospital survey and wrote a report of the findings. Dr. Eula Aiken, SREB staff member, did the same for responses from the schools. 3. A 15-member panel of experts, drawn from the South, was appointed, reviewed the five papers, and met in Atlanta on October 5—6, 1987 to develop conclusions and recommendations. 4. Dr. Ruth Yurchuck examined the notes of the panel’s discussions and prepared a summary of conclusions and recommendations. This draft summary was mailed to each of 15 panel members for their comments and approval. The summary conclusions and recommendations were revised after receiving the panel members' comments. 5. The final task in this regional activity is completed with the submission to the Division of Nursing of this document containing the conclusions and recommendations of the panel of experts, three monographs, and two reports of regional studies. Audrey F. Spector Nursing Programs Director Southern Regional Education Board viii CONCLUSIONS AND RECOMMENDATIONS 0F PANEL 0F EXPERTS Summarized by Ruth Yurchuck Introduction A panel of experts was convened in Atlanta on October 5-6, 1987, by the Southern Council on Collegiate Education for Nursing (SCCEN) to examine the impact of Diagnosis Related Groups (DRGs) and implications for undergraduate nursing education. These 15 experts heard five formal papers/presentations and participated in extensive roundtable discussion sessions. The specific goals of the meeting were to examine data presented, identify trends and specific problems seen for the South, and formulate recommendations for the clinical and didactic nursing curricula of undergraduate nursing education programs. The conclusions and recommendations which follow were derived from analysis of the five major papers and notes summarizing the roundtable discussions. Conclusion I. The nature of clinical nursing practice in hospital and community settings is changing. Clients in the Southern region are characteristically older; more culturally and ethnically diverse; reside in rural areas, with developing areas of urban concentration; have limited formal education, with increasing migration into the South of college-educated persons; are economically disadvantaged; and are growing in numbers. Like clients in other regions, they are more acutely ill during hospitalization and are discharged with a relatively high acuity level; they require complex nursing care in both settings. Quality of care provided generally is adversely affected when coordination of care during hospitalization and from hospital to home is lacking. When client hospitalization is required, there is generally a short length of stay; length of stay is strongly affected by the client's Diagnosis Related Group. Hospitals and community agencies are placing greater emphasis on cost-containment, employee productivity, and ways to increase revenue. Smaller hospitals are being forced to close. Use of management information and patient classification systems is evident. Recognition of the importance of client/family teaching, discharge planning, and thorough, accurate documentation is also apparent. Increased competition among hospitals, and competition among community agencies, has led to diversification and provision of specialized services. Hospital care involves increasing use of technology. Insurance coverage is becoming more available for selected home care services and improved technology is making possible increasingly complex health care. Less financial support is being provided for clinical education of health personnel. There is increased competition among hospitals and community agencies for limited nursing resources. The supply of nurses in the Southern region is decreasing at the same time the demand for well-prepared skilled clinicians to staff hospitals and community agencies is increasing. The greatest number of practicing Registered Nurses (RNs) have been prepared at the associate degree level. Workloads of hospital and community nurses have increased and the level of care required by clients is more intense. Among hospital nurses, turnover rates are increasing and issues of retention, productivity of current staff, and quality of care are increasingly significant. Coordination of care between hospital and community nurses is essential to maintaining quality of care provided. The public image of nursing as largely hospital-based creates the impression that career opportunities are limited to staff nurse positions or that nursing as a career has little future as hospitals close units or are forced to close entirely. Recommendations related to Conclusion I. 1. Increase efforts to recruit students into undergraduate nursing programs, particularly at the baccalaureate level. 2. Enhance the image of nursing as a viable career by emphasizing diversity of career opportunities. 3. Increase funding at state and federal levels to expand baccalaureate nursing programs and scholarship assistance, and to prepare additional nursing faculty at the graduate level. 4. Increase collaboration between nursing service and nursing education that will lead to: a) more realistic delineation of the educational preparation needed for current and future nursing practice; b) research efforts to improve or develop different models for both nursing practice and nursing education; and c) development of models of care that will improve quality of care provided to clients in hospital and community settings. 5. Develop models to promote retention of nursing staff. 6. Develop systematic programs of continuing education for nursing staff in hospitals and community agencies that will increase their competence in providing high quality care in a cost-effective manner. Nurses in both settings need to increase their understanding of health care economics, particularly the prospective payment system and DRGs; their assessment, priority-setting, and decision-making skills; and to learn to deal with the increasing complexity of care required by clients, who are older and both acutely and chronically ill. Nurses in both settings also need well planned orientation to their agencies, including the type of documentation required for reimbursement of services provided and the type of technology and equipment with which they have to work. Conclusion II. A variety of modifications in current undergraduate curricula have been proposed by nursing administrators and nursing educators as a result of DRGs and the changing health care scene. These modifications include additional content areas and creative instructional methods. There are insufficient data to indicate which content is already in place and there is no consensus as to where and how content would or should be incorporated into undergraduate curricula. Content areas identified for consideration in undergraduate curricula include: multi-ethnic characteristics of the population in the Southern region; health policy; specific gerontological content; health care economics, including prospective payment systems and DRGs; political, economic, and legal issues in health care; computer technology and communication systems in health care settings; health promotion and disease prevention; home care; client teaching and counseling, including discharge planning; complex care for acutely and chronically ill clients; decision-making in complex care situations, including what constitutes adequate treatment; substance abuse; client assessment; technology of health care; and clinical synthesis. There was no implication that these content areas were equivalent to one or more courses in undergraduate curricula but only that they need to be considered, included, or addressed at some point in some way. Instructional methods which could be used to increase student awareness of health care economics and the impact of prospective payment include: nursing economics grand rounds; placing market value on equipment used in the college skills lab; requiring students to read selected articles on prospective payment and DRGs; and case and clinical approach for teaching nursing ethics. Recommendations related to Conclusion II. 1. Improve articulation between associate degree and baccalaureate nursing programs. 2. Conduct a regional analysis of undergraduate curricula. 3. Select carefully non-nursing courses to serve as a foundation for building nursing knowledge and competence. 4. Seek funding to support curricular modifications. Conclusion III. The nature of clinical learning experiences in undergraduate curricula has been affected by prospective payment and DRGs. New approaches are needed to ensure that graduates are prepared for the complexities of current nursing practice in a variety of settings. As client acuity increases, students need more structured preparation in college skills labs prior to clinical experience. In some instances, simulation labs may take the place of clinical experience in acute care settings. Experiences that provide continuity of care for clients and students are increasingly important, as are experiences in client/family teaching, discharge planning, and documentation. The emphasis on community-based clinical experiences, including home care, is growing. Selection of appropriate clinical learning experiences is increasingly important. The ratio of faculty to students in clinical settings may need to be increased because the number of staff available to assist student learning is decreasing. Recommendations related to Conclusion III. 1. Increase student awareness of health care economics, patient classification, management information systems, and other technologies in clinical experiences. Increase collaboration between nursing faculty and clinical staff to choose appropriate learning experiences. Greater consideration as to clinical sites, selection of clients for clinical assignments, and monitoring of these clinical experiences. Place greater emphasis on faculty maintaining their clinical competence. Provide continuing education for faculty to improve their awareness of health care economics. DRGs--IMPLICATIONS FOR UNDERGRADUATE NURSING CURRICULA Frances C. Henderson INTRODUCTION Changes in the reimbursement of hospitals under the prospective payment system have had a major impact on the requirements for clinical nursing in both hospital and community settings. Included in the impact on clinical nursing in hospital settings is patient length of stay, case mix, and care requirements. In hospital settings, there is a dramatically increased need for more highly skilled nurses to care for sicker patients, and a greater demand for nurses skilled in critical care. Included in the impact on clinical nursing in community settings is the increased need for nurses prepared to deliver nursing care in the growing home health care industry, in hospices, and in community health and ambulatory care settings. Changes in the reimbursement of hospitals under the prospective payment system have had a dramatic effect on hospital system organization and administration and on the administration of nursing services. Some hospitals, to become cost effective, specialize in treating a particular case mix of patients or in treating specific Diagnosis Related Groups (DRGs) rather than having equipment and personnel available to accommodate all types of patients and diagnoses. Multi—hospital corporations emphasizing productivity, cost effectiveness and profit are an ever increasing reality. The administration of nursing services requires sophisticated data for staffing, resource management, and fiscal management. Patient classification systems to determine the cost of nursing and the use of computers for analyses comparing patient treatment and resource consumption according to DRG category are commonplace. The mismatch between position expectations of nursing service and the educational preparation by nursing programs has escalated in spite of local, statewide, and regional efforts to bridge the gap between nursing education and nursing service. Nursing’s response to the Prospective Payment System is influenced by several factors including: commitment to quality care, client consumerism, demographics of America's population, the nursing shortage, competition for nursing resources and the hospital's role in clinical education of health personnel. Quality care issues are viewed not only from the perspective of formal quality assurance programs but must be cost effective and well documented, and must include increased emphasis on teaching patients and families prior to discharge. While consumerism based on the restructuring of health care incentives theoretically emphasizes clients' responsibility for wellness, America's increasing aging population must be considered. The publicizing of hospital census drops, the closing of units and small hospitals, and the consequent cuts in hospital nursing staffs resulting from the initial impact of DRGs may have contributed to an image by the public of nursing as a career with little future. In reality, nurses in home health agencies have become a valuable commodity to handle sicker patients who are being discharged quicker from acute care facilities. Competition for nurses between hospitals and free-standing ambulatory care outpatient facilities is still another DRG-related effect. Financial support to hospitals for clinical education has decreased and is expected to continue to decrease or be eliminated, forcing hospitals to more closely scrutinize their roles as sites for clinical education. The implications for changes in nursing education are both implicit and explicit. Documentation supported by hard data and soft data is needed to provide substantive direction for undergraduate nursing curricula. These data should be region-specific and should provide descriptive information for nursing education and nursing practice to appropriately modify undergraduate clinical and non-clinical courses. This monograph presents characteristics of undergraduate nursing programs in the Southern region including: types of programs, growth factors, annual admissions, total enrollments, and graduations by type of program and by region in proportion to the United States. Demographic characteristics and population growth projections in the Southern region are included, from which projections of nursing needs and types of nursing resources needed can be made. Specific modifications of undergraduate nursing curricula, including nursing content and clinical courses as well as non-nursing support courses, will be presented from the perspective of current realities and future projections. The data and strategies presented in this monograph will contribute to a compendium of facts, figures, and strategies that can be examined by a panel of experts to provide direction for implementing the necessary changes in undergraduate nursing curricula. CHARACTERISTICS OF UNDERGRADUATE NURSING PROGRAMS IN THE SOUTHERN REGION The Southern region has demonstrated its greatest growth in the number of undergraduate nursing programs over the 10-year period from 1976 to 1985. Compared to other regions of the country, the South has the largest number of nursing education programs leading to R.N. licensure, the largest proportion of undergraduate baccalaureate nursing programs, and the largest number of baccalaureate programs graduating registered nurses with previous nursing education at the associate degree level. Data which illustrate the characteristics of undergraduate nursing programs in the Southern region are compared and contrasted with the United States as a whole and with the North Atlantic, Midwestern, and Western regions.* Undergraduate Nursing ProgramsI by Region and by Proportion of Programs in the United States In 1985 there were 1,473 undergraduate nursing programs in the United States. Of these, the South reported 485 programs, almost 33 percent of the total and the largest proportion of undergraduate nursing programs by region. (see Table 1) when compared to the Midwest (29.4 percent), the North Atlantic (23.9 percent), and the West (13.9 percent) (Rosenfeld, 1986). Growth of Undergraduate Nursing Programs, by Region In terms of growth over the 10-year period from 1976 to 1985, the Southern region has shown a steady increase in the number of undergraduate nursing programs, with an overall increase of 81 programs (17 percent). The North Atlantic region showed an overall decrease in programs-~from 384 in 1976 to 350 in 1985; in the Midwest and West the overall growth in number of programs was 10 percent and 11 percent, respectively (see Table 2) (Rosenfeld, 1986). *States in each of the four National League for Nursing regions are: §gu£h, Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia; North Atlantic, Connecticut, Delaware, District of Columbia, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont; Midwest, Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin; Western, Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, Wyoming. Note: Oklahoma data not included in this study. 10 TABLE 1 Undergraduate Nursing Programs, by Region and by Proportion of Programs in the United States, 1985 393193 flgmbg; Percent United States 1.473 100.0 South 485 32.9 North Atlantic 350 23.9 Midwest 433 29.4 West 205 13.9 Source: Derived from National League for Nursing data, Rosenfeld, P. (1986) TABLE 2 Growth of Undergraduate Nursing Programs, by Region Number of Programs Region 1976 1985 Increase/ Percent Decrease Change South 404 485 +81 17% North Atlantic 384 350 -34 10% Midwest 388 433 +45 10% West 182 205 +23 11% Source: Rosenfeld, P. (1986). New York: National League for Nursing The Southern region also has the largest percentage of the nation's baccalaureate undergraduate nursing programs in the four regions (34.2 percent), as well as the largest percentage of the nation's associate 11 degree nursing programs (36.7 percent). The Southern region has the second smallest percentage of diploma nursing programs (19.1 percent); the smallest percentage of diploma programs (1.6 percent) are in the Western region. (see Table 3) (Rosenfeld, 1986). TABLE 3 Percent of Program Type, by Region Total South Midwest North Atlantic West Baccalaureate 100.0 34.2 29.7 24.3 11.8 Associate 100.0 36.7 26.4 17.7 19.2 Diploma 100.0 19.1 37.9 41.4 1.6 All Programs 100.0 32.9 29.4 23.8 13.9 Source: Derived from National League for Nursing data. Rosenfeld, P. (1986). Growth of Undergraduate Nursing Programs, by State In this presentation of data, 14 of the SREB states are included. The 15th SREB state, Oklahoma, is included in the Midwest Alliance in Nursing for this activity. Of the 14 states, 12 have experienced growth in undergraduate nursing programs which ranges from 3 percent in Georgia to 28 percent in Florida. The number of new programs by state ranged from 1 to 12; North Carolina and Texas each had an increase of 12 new undergraduate nursing programs over the lO—year span. Arkansas had 20 undergraduate nursing programs both in 1976 and 1985; Virginia had 38 undergraduate nursing programs in 1976 and 37 in 1985 (see Table 4) (Rosenfeld, 1986). Admissions, Enrollments and Graduations, Nationwide and by Region, 1983-1985 In 1985, the total number of students admitted to undergraduate nursing programs nationwide was 118,224; of these 32 percent were admitted to programs in the Southern region. These are the number of first-time nursing students 12 admitted in the 13-month period between July of one year and August of the following year. Annual admissions for 1985 nationally showed a 5 percent decrease over 1984, when admissions reached an all time high of 123,824. The number of annual admissions to undergraduate nursing programs in each region also dropped from 1984 to l985--4 percent in the South. The North Atlantic TABLE 4 Growth of Undergraduate Nursing Programs, by SREB State, 1976-1985 Number of Programs 1976 1985 Increase Percent Increase Alabama 27 36 9 25% Arkansas 20 20 0 —- Florida 28 39 ll 28% Georgia 33 34 l 3% Kentucky 25 28 3 11% Louisiana 16 22 6 27% Maryland 21 25 4 16% Mississippi 21 22 1 5% North Carolina 45 57 12 21% South Carolina 15 20 5 25% Tennessee 28 33 5 15% Texas 53 65 12 18% Virginia 38 37 (-1) -- West Virginia 16 18 2 11% Source: Derived from National League for Nursing, data. Rosenfeld (1986) 13 TABLE 5 Admissions, Enrollments, and Graduations, Nationwide and by Region, 1983-1985 United States South Midwest North Atlantic West Admissions 1983-84 123,824 39,756 35,630 31,964 16,654 1984-85 118,224 38,089 33,478 31,738 14,919 Increase/ Decrease -5,600 - 1,487 ~2,152 -226 —1,735 Percent Change —5% -4% —6% -1% -10% Enrollments 1983-84 237,232 69,343 69,521 68,798 29,570 1984—85 217,955 63,911 63,247 63,673 27,124 Increase/ Decrease -l9,277 -5,432 -6,274 -5,125 —2,446 Percent Change -8% -8% -9% -7% -8% Graduations 1983-84 80,312 24,308 25,041 19,897 11,066 1984—85 82,075 25,181 25,208 20,484 11,202 Increase/ Decrease +1,763 +873 +167 +587 +136 Percent Change +2% +4% +1% +3% +1% Source: Derived from National League for Nursing data. Rosenfeld, P. (1986). 14 showed the least drop in annual admissions ( 1 percent), the West showed the most severe drop (10 percent), and the Midwest reported a 6 percent decline (see Table 5) (Rosenfeld, 1986). Analysis of a 10-year trend of annual admissions, 1976-1985, revealed an overall 5.4 percent increase in annual admissions. Admissions to undergraduate baccalaureate programs rose almost 9 percent, and to undergraduate associate degree programs almost 22 percent. Admissions to undergraduate diploma nursing programs have decreased 37 percent over the last decade (Rosenfeld, 1986). As of October 1985, the total number of students enrolled in undergraduate nursing programs nationwide was 217,455. Of these, 63,911 (29 percent) were enrolled in undergraduate nursing programs in the Southern region. Total enrollments decreased 8 percent from 1984 to 1985. The South showed an 8 percent decrease in enrollments, the smallest decrease (7 percent) was in the North Atlantic, and the Midwest had the largest, 9 percent (see Table 5) (Rosenfeld, 1986). Viewed from the perspective of 10-year trend data (1976-1985), enrollments in all undergraduate nursing programs have decreased 12 percent. Enrollments in undergraduate diploma programs decreased by 50 percent and baccalaureate programs by 8.8 percent; associate degree programs reflected an enrollment increase of 8.9 percent (Rosenfeld, 1986). In 1984-85, the total number of students graduated from undergraduate nursing programs nationwide was 82,075. Of these, 25,181 (31 percent) graduated from undergraduate nursing programs in the South. The 1984-85 graduation figure was an all-time high and reflected a 2 percent increase over 1983-84 (see Table 5) (Rosenfeld, 1986). Graduations from undergraduate baccalaureate programs increased by 5.3 percent, and from associate degree programs by almost 2 percent. The South showed the largest increase in graduations, 4 percent. 15 Graduations 9f R.N.s from Baccalaureate Nursing ProgramsI by Region and Previous Basic Nursing Education, 1980-81 and 1984-85 In 1980-81, the nation had a total of 348 baccalaureate programs that reported graduations of registered nurses (R.N.s); 99 of these programs were in the South. Of these R.N. graduates, 45 percent received their previous basic nursing education in diploma programs; 55 percent were initially graduates of associate degree nursing programs. By 1984-85, the Southern region had the largest number of baccalaureate programs which reported graduations of R.N.s-—l89 programs (31 percent); there were 602 such programs nationwide. Of the 1984-85 R.N. graduates, 34 percent received previous basic nursing education in diploma programs; 66 percent were initially nursing education in diploma programs; 66 percent were initially graduates of associate degree nursing programs. The largest group of R.N. graduates from baccalaureate programs were in the North Atlantic region (31 percent); the second largest group, 27 percent, were in the Southern region (see Table 6) (Rosenfeld, 1986). Modifications of Undergraduate Nursing Curricula Based on DRG Implications and Characteristics of Undergraduate Nursing Curricula in the Southern Region Undergraduate nursing programs in the Southern region, by virtue of their sheer numbers, growth trends, and large number of generic and R.N. graduates, are in a prime position to become leaders nationwide in effecting changes in undergraduate nursing curricula that respond to the implications of DRGs on the preparation of nursing graduates. The large number of R.N. graduates from the largest number of baccalaureate programs that enroll them, in comparison to other regions, indicates a trend in the South toward the preparing of nurse greduates for community clinical settings. The large percentage of 16 TABLE 6 Graduations of R.N.s from Baccalaureate Nursing Programs, by Region and Previous Basic Nursing Education, 1980-81 and 1984-85 Number of Bacc Programs Total with RN Number mm Graduations Percent Graduations Percent Diploma Percent ADN Percent 1980-81 United States 348 -— 8,195 -- 4,172 -- 4,023 -- South 99 28% 2,248 27% 1,013 45% 1,235 55% Midwest 106 30% 2,374 29% 1,267 53% 1,107 47% North Atlantic 98 28% 2,470 30% 1,446 59% 1,024 41% West 45 13% 1,103 13% 446 40% 657 60% 1984-85 United States 602 -- 9,594 -- 4,115 -- 5,479 -- South 189 31% 2,588 27% 887 34% 1,701 66% Midwest 180 30% 2,709 28% 1,437 53% 1,272 47% North Atlantic 156 26% 2,946 31% 1,422 48% 1,524 52% West 77 13% 1,351 14% 369 27% 982 73% Source: Derived from National League for Nursing data. Rosenfeld (1986). 17 baccalaureate and associate degree programs in the South indicates the region's potential for preparing nurses at both technical and professional levels. It also pinpoints the sites where changes in undergraduate nursing curricula, based on the implications of DRGs, will need to occur. The decrease in admissions and enrollments of students in undergraduate nursing programs indicates a need for recruitment efforts that include an enhanced image of nursing as a career with a future and the opportunities for nurses in other than hospital settings. This will open the way for changes in the public's perception of nursing in the wake of publicity implying the opposite as a result of DRGs. The increase in the number of graduates from undergraduate nursing programs in the Southern region, despite decreases in admissions and enrollments, is a highly positive sign for the success of undergraduate nursing education in the region, and provides fertile ground for planning and implementing curricula modifications. POPULATION, EDUCATION, AND ECONOMY IN THE SOUTHERN REGION Over one-third of the nation's population is in the South--nearly 81 million people. The population growth rate, which has been nearly twice the national growth rate, is expected to continue until the turn ofthe century. Most of the region’s projected growth (60 percent) is expected to take place in Florida and Texas (Marks, 1986). These are two of the three emerging "megastates" identified by Naisbitt (1982). Among the characteristics of megastates is their attraction to a highly international population. Florida and Texas populations already reflect a great increase in persons from Mideastern, Latin American, Carribean, and Hispanic-American cultures (Naisbitt, 1982). Minorities will represent a larger proportion of the 18 school—age and college-age populations in the years ahead. In the last census, black, Hispanic, and other minorities were one of every four persons in the Southern region (Marks, 1986). Population growth in the Southern region increases its political power. Two of the three states which were big winners of Congressional seats after the 1980 census were in the South. Florida gained four seats while Texas gained three (Naisbitt, 1982). A larger proportion of the South's population resides in rural areas than is true for the nation as a whole. In 1986, only 62 percent of the region's population lived in metropolitan areas, compared to nearly 75 percent of the population nationwide. The trend in the Southern region is toward increases in the proportion of the population living in metropolitan areas (Marks, 1986). Between now and the turn of the century, the "Aging of America" will become more and more evident in the South. Young adults (ages 15 to 24 years old), who accounted for one of every five people in 1980, will be only 13 percent of the total population in the year 2000 (Marks, 1986). According to Naisbitt (1982), by the year 1995, the entire U. S. population will reflect the same age-youth ratio that Florida now has. In 1980, Florida had the nation's oldest population and there has been evidence of growing tensions between the state's older and younger residents. Adults in the Southern region average fewer years of formal education than adults nationwide. Nearly 23 percent (10 million people) have not completed ninth grade--a level of education often used to define "functional literacy"--compared to 18 percent nationwide. In the Southern region, 60 percent of adults are high school graduates--7 percent lower than the national average of 67 percent. By the end of the 19803, the number of high school graduates is expected to increase sharply in the Southern region and to fall sharply nationally (Marks, 1986). 19 Appropriations for higher education operating expenses have historically accounted for a larger proportion of state taxes in Southern states than nationwide. Higher education receives an average of 16 percent of state taxes in the South compared to a national average of 13 percent. However, both nationally and in the South, the proportion of state taxes appropriated to higher education fell between 1982 and 1984 (Marks, 1986). According to Marks (1986) and Naisbitt (1982) the Southern region is experiencing an increased migration of college-educated people, providing increased human resources in spite of constrained or static fiscal resources. In 1984, income per person in the South reached $ll,662--91 percent of the national average of $12,789. There has been little relative gain by the region's states in the last five years. Total employment has grown faster than nationwide but unemployment rates are higher. A shift from an agricultural, mining, and manufacturing base to a trade and service economy has generally spurred metropolitan strength and weakened non-metropolitan economics. Until recently, areas dependent upon oil and gas revenues have been high economic growth areas (Marks, 1986). According to Naisbitt (1982), per capita income increased most in the Southwest (167 percent during the past decade) and least in the Middle Atlantic and New England states. Modifications of Undergraduate Nursing Curricula Based on DRG Implications and Population, Education, and Economy in the Southern Region Demographic characteristics of the Southern region, including population growth predictions, are of great importance to the modifications of undergraduate nursing curricula in response to the implications of DRGs. The rapid population growth indicates the need for an increase in clinical nursing services in hospital and clinical settings. The growing multicultural and 20 multi-ethnic make-up of the region's population has implications for students as well as clients. Students will need to have curricula modifications sensitively structured around ethnic and cultural characteristics, theirs and their clients'. Clients will need to have nursing actions administered with transcultural sensitivity. Because a larger proportion of the South’s population presently resides in rural areas, the implications of DRGs on the delivery of nursing services to this population will need to continue to be addressed. At the same time curricula modifications will be necessary to address the needs of a population which is also moving from rural to metropolitan areas. In the political arena, nurses and consumers will need to engage in joint efforts to interpret and address the implications of the current DRG policy and to influence future national health policy. The nurses's role in the shaping and interpreting of health policy and nurses' political action responsibilities will need to be included or enhanced in the modification of undergraduate nursing curricula. Modifications of undergraduate nursing curricula in response to the implications of DRGs will need to be addressed for clients across the life span, with increasing emphasis on the region's aging population. The educational profile of the region's population is also a factor. Nursing students will need to master the content in specific, carefully selected non-nursing courses in the natural sciences and social sciences, including political science and economics as well as courses in computer science. These will provide the background upon which to build increasingly complex nursing knowledge and expected competencies. They will also provide some of the essential tools with which to interpret and analyze nursing assessments, structure nursing diagnoses, and plan, implement, and evaluate nursing actions. A variety of client and family education approaches will be needed to 21 effectively deliver necessary teaching regarding self-care. One major implication of DRGs for client care is an increasing need for teaching clients and families to provide care after multisystem diagnoses requiring chronic, long-term care in out-of-hospital settings. To address modifications in undergraduate nursing curricula, fiscal appropriations for higher education will need to be adequate to provide for faculty time to devote to curricular changes without compromising the continuing of nursing education programs. Continuing education programs to increase faculty knowledge and application of DRG implications will need to be implemented. Appropriations will need to be adequate to attract and maintain the reported influx of college-educated people to the Southern region. And, they will need to be adequate to provide higher education for new nursing faculty to effectively meet the educational needs of the more than 60,000 enrollees in the region's undergraduate nursing programs. Nursing faculty involved in modifying undergraduate nursing curricula will need to consider that, despite the reported average income at 91 percent of the national average, a greater proportion of the region's population lives below the poverty level. The implications for undergraduate nursing curricula in response to the implications of DRGs will greatly affect the preparation of nurses who will deliver nursing care to a population whose survival needs take precedence over their compliance with health care incentives. SPECIFIC MODIFICATIONS 0F UNDERGRADUATE NURSING CURRICULA IN RESPONSE TO DRG IMPLICATIONS Most of the literature in nursing and nursing-related publications to date addresses the implications of DRGs on nursing service, especially nursing management and nursing administration. These articles address subjects such productivity, cost containment, pricing of nursing services, and quality 22 assurance. Some deal with the effects of prospective pricing on home care and community clinical experiences, speciality nursing clinical practice, and various age groups of clients, especially the elderly. The implications for undergraduate nursing curricula are more implicit than explicit. Among the 150 print media resources collected as background for this monograph, 11--less than 10 percent——explicitly address implications for undergraduate nursing curricula. Current Modifications In fall 1984, Redman and Cassells (1985) surveyed 246 deans from American Association of Colleges of Nursing (AACN) schools to gather data about the emphasis placed on health care issues and trends having an impact on nursing education and practice. Included in the list of trends and issues was a survey tool designed to determine if and how DRGs and other prospective payment systems influenced their nursing programs. A total of 174 deans responded to the survey. Of the respondents, 71 percent indicated that, indeed, DRGs and other prospective payment systems had influenced their nursing programs (Redman and Cassells, 1985). The survey included 11 items designed to elicit the extent to which respondents' nursing programs were influenced. Three items received a more than 50 percent response. They were: increased emphasis on home care/community clinical experiences, increased emphasis on political/economic/legal issues in nursing curriculum, and changes in clinical placements and/or clinical hours (see Table 7) (Redman and Cassells, 1985). According to Redman and Cassells (1985), payment by DRGs were reported to have influenced programs more in the West (85 percent) and Midwest (81 percent) than in the South (70 percent) or Northeast (59 percent). In September 1987, this author made minor modifications in the Redman and Cassells survey tool and conducted a pilot survey of 15 deans and directors of undergraduate nursing programs in Mississippi. The group used for this pilot 23 TABLE 7 Influences of DRGs on Nursing Programs in a Sample of AACN Member Schools Item (n-174) N Percent Increased emphasis on home care/community clinical experience 133 76% Increased emphasis on political/economic/ legal issues in the nursing curriculum 103 59% Necessitated changes in clinical placements and/or clinical hours 94 54% Source: Redman and Cassells (1985). survey comprises the Mississippi Council of Deans and Directors of Schools of Nursing. Council members represent all undergraduate nursing programs in Mississippi——12 associate degree programs and 7 baccalaureate programs. The Council meets monthly to address issues and trends affecting nursing education in the state and their relationship to regional and national issues and trends. All representatives present at the Council meeting responded to the survey tool for a pilot population of 15. 0f the 15 respondents, 14 (93 percent) indicated that DRGs or other prospective payment systems influenced their nursing curriculum. The next greatest response, 73 percent, indicated that there is increased emphasis on home care and community clinical 24 experiences. each item are illustrated in Table 8. TABLE 8 Pilot Survey Results: Nursing Curricula in Mississippi The modified survey tool and number and percent of responses to Influences of DRGs on Undergraduate Responses N-lS Number Percent Have DRGs or other prospective payment systems influenced your undergraduate nursing curriculum? a. Yes 14 93% b. No l 7% If yes, describe how by checking all that apply. a. Necessitated changes in clinical placements, and/or clinical hours. (Please give examples) 6 40% b. More simulated clinical activities are used as the in-patient hospital population decreases 4 27% c. Increased emphasis on home/care community clinical experiences 11 73% d. Increased emphasis on the development of critical nursing skills for patient care in community settings (ventilator care, chemotheraphy administration, etc 3 20% 25 N-15 Responses Number Percent Alteration in clinical requirements, such as, abbreviated nursing care plans and focus on discharge planning including patient/family teaching Increased emphasis on political/economic/ legal issues in nursing curriculum Increased collaboration with nursing service agencies to better prepare nurses in caring for patients with shorter length-of-stays Implementation of instruction for faculty and students to better prepare them for confronting ethical/economic issues associated with health care cost containment Increased faculty involvement in direct clinical practice to enhance their understanding of the implications of health care economics on quality of nursing care No effect Other (Please specify) 6 40% 7 47% 7 47% 6 40% 5 33% 26 Spontaneous written comments included the following: "Freshmen (AD) students couldn't be placed on formerly used units due to acuity level of patients." "We've implemented home health clinical experiences for AD students." "We’ve contracted for additional clinical experiences." "Increased use of outpatient hospital services." "Content is included on impact of DRGs." "We're having tremendous problems exposing students to low-risk, primary prevention. We are fortunate to now have access to student health service on campus." In mid-August 1987, the Executive Director of the Southern Council on Collegiate Education for Nursing mailed a survey on Diagnosis Related Groups to 100 member schools and to a sample of fifth hospital in the region with over 50 beds. This survey included 31 items designed to elicit information about of DRGs on undergraduate nursing curricula in the South. The results of this survey will be presented separately. Suggested Strategies and Predictions for Future Modifications Many modifications in undergraduate nursing curricula will emanate from those already being experiences, according to surveys of nurse educators. These include the following: Expanding clinical learning experiences to include college and university student health centers, home health agencies, ambulatory care and outpatient facilities, as well as college and university-based nursing centers. According to Davis (1985), health care centers which offer the full spectrum of health-care services from cradle to grave will replace the traditional hospital of today. 27 Implementing or expanding the use of clinical simulations, including testing clinical competence prior to clinical rotations, so that students are well-prepared to be productive and to perform nursing procedures including accurate documentation within the time, fiscal and resource parameters of the clinical agency. Scheduling clinical rotations in short blocks with consecutive clinical days so as to provide continuity of care experiences for both students and clients. Including in nursing curricula content related to DRGs, for example, the basic terminology of prospective payment systems. Including in nursing curricula increased emphasis on the development of critical nursing skills, including decision-making skills, as well as increased emphasis on political, economic, legal, and ethical issues. Increasing faculty involvement in direct clinical practice to enhance their understanding of the clinical implications of prospective payment systems on the delivery, management, and coordination of nursing services. Other strategies are reflected in literature by nurse educators, some of which reports the implementation of innovative methods to modify content and instructional approaches, while some poses what should be, how, and why. Examples follow: One way to develop students' cost awareness early in the educational process is to place a current market value on all equipment that students use in practice laboratories, including thermometers, bed linen, disposable trays, and intravenous solutions and tubing as well as speciality equipment (Mutzebaugh, 1986). Creativity in clinical instruction can help faculty adjust to teaching in hospitals with decreased resources and a declining census. The concept of 28 cost can be integrated throughout the curriculum just as the concept of nursing process is. Students must have opportunities to understand and practice cost containment in patient care settings (Mutzebaugh, 1986). A lecture-clinical course for senior baccalaureate nursing students in "clinical synthesis" (Mutzebaugh, 1986). "Nursing economic grand rounds" and other exercises that will introduce nursing students to health care costs and cost containment should be initiated early in the nursing curriculum and repeated periodically throughout the program. The financial aspect of care must be incorporated into the total patient picture (Perlich, 1985). Equipment used for students' practice in the simulated skills laboratory needs to be up-to-date and similar to, if not the same as, that used in the hospital. Human volunteers for nursing care procedures might have to be considered (Perlich, 1985). Faculty need to read the wealth of material on prospective payment systems that is being published. The most pertinent of these articles should then be required reading in all nursing courses (Perlich, 1985). Nurse educators and nurse managers of the clinical units where students are assigned should meet frequently to discuss the units' budget, financial reports, and areas of resource over-consumption. This data should be shared with students and included in the clinical and didactic content of the nursing program (Perlich, 1985). Using a "case and clinical approach" for teaching nursing ethics (Stanley, 1980). "Using elective courses to create social and political awareness" in an undergraduate baccalaureate nursing curriculum (Schutzenhofer and Spikes, 1986). 29 Assertion of the cost efficiency of baccalaureate preparation for productivity in service in major roles such as care-giver, manager/leader, health promotion/supervision, teaching/counseling, and health/illness screening (Houston and Cadenhead, 1986). Emphasis in undergraduate nursing curriculum on: addressing the process of aging, including nutrition, medication, and home care. Other areas include teaching, speaking, counseling, and research; efficient utilization of human resources and organization strateSY; a sense of responsibility for supporting community activities and contributing to local, state, and national policy forums and health care planning groups, as well as a focus on how nursing makes a difference (Smith, 1984). Integrating health-care policy into the curriculum (Fagin and Haraldo, 1981). Enhancing student awareness of how DRGs will affect working conditions and hiring and fostering the development of positive attitudes about changes that occur with prospective payment systems (Smeltzer and Flores, 1986). Educating larger numbers of baccalaureate nurses, which would involve: (1) additional outlays by state governments--the primary source of funding; (2) expanded support from the federal government for the training of additional faculty, scholarship funds, and other infrastructure assistance; and (3) most importantly, the willingness of more potential nursing students (and their families) to assume the substantial short-run costs connected with a four—year program of undergraduate studies (Ginzberg, 1981). Additional major approaches to further identify modifications of undergraduate nursing curricula in response to DRG implications are: Articulation of diploma undergraduate education and associate degree nursing education with baccalaureate nursing education on a statewide or regional basis. 30 The development of statewide competency-based models for nursing education and practice (South Carolina's Statewide Master Planning Committee on Nursing Education, 1986). Collaboration between nursing service and nursing education to identify the competencies required by nurses for current and future employment and promotion, the types and amount of clinical and non-clinical learning experiences which would best prepare them, and the sharing of resources to mutually meet the challenges to nursing practice, education, and research generated by the prospective payment system (Whitney, 1986) (Conway—Welch, 1985). Realistic and effective career management by nurses. Nurses must take the initiative in identifying and promoting their unique services to effectively compete in today's marketplace (Krampitz and Coleman, 1985). Exploration of external funding to help expedite the most pressing curricula modifications. More publications by nurse educators about innovative curricula modifications and strategies which respond to DRG implications as well as an annotated bibliography os resources that have already been published. Modification and amalgamation of the two survey tools designed to elicit data about the influence of DRGs on undergraduate curricula and administration of revised tool to representatives from each of the 485 undergraduate nursing programs in the Southern region. Results from such a survey would provide specific data upon which to base regional efforts related to modification of undergraduate nursing curricula. To meet accreditation standards and to remain viable, dynamic, and responsive to learner needs, undergraduate nursing curricula are in a cyclic state of vivification. The impact of DRGs on clinical nursing points out 31 substantive direction for significant modifications. Characteristics of undergraduate nursing programs in the South, along with the region's demographic characteristics, will help to shape modifications in undergraduate nursing curricula to the unique needs of the region. 32 References Blalock, B. (1987, June 23). Shortage a critical illness afflicting nursing. The Birmingham News, pp. 1D, 3D. Conway-Welch, C. (1985). DRGs, nursing education, and nursing service: A collaborative effort for survival. In F. Shaffer (Ed.), Costing out nursing: Pricing our product (pp. 173-182). New York: National League for Nursing. Davis, C. (1986). Health care reforms. What can we expect? Nursing Economics. fl (1), 10—11 & 49. Durenberger, D. (1986). Legislative perspective on health care in 1986 Nursing Economics 5 (1), 6-9. Fagin, C. & Maraldo, P. (1981). Health policy in the nursing curriculum: Why it's needed. New York: National League for Nursing. Gingzberg, E. (1981). The economics of health care and the future of nursing. Nurse Educator Q (3), 29-32. Houston, S. & Cadenhead, c. (1986). DRGs and BSst The case for the baccalaureate nurse. Nursing Management 11 (2), 35-36. Krampitz, S. & Coleman, J. (1985). Marketing-A must in a competitive health-care system. Nursing Economics 1 (5), 186-289. Marks, J. (1986). SREB fact book on higher education 1986. Atlanta: Southern Regional Education Board. Mutzebaugh, C. (1986). Developing a cost awareness in nursing students. In F. Shaffer (Ed.), Patients & Purse Strings, (pp. 307-317). New York: National League for Nursing. Naisbitt, J. (1982). Meggtrends. New York: Warner Books. 33 REPORT OF A SURVEY OF UNDERGRADUATE NURSING SCHOOLS IN THE SOUTH ON THE IMPACT OF DRGs Eula Aiken A survey was administered in August 1987 to 100 schools of nursing in the South to collect information about the impact of the prospective payment system on clinical nursing in hospital and community settings and the implications for undergraduate nursing education. The findings (derived from 48 returns) indicate: 67% (n-32) of the educators had "adapted [the] curriculum to prepare nurses for the DRG system" by including DEG—related information in content areas, e.g., "cost containment," "assessment skills," "historical development," "discharge." 73% (n=35) had not "conducted continuing education programs to prepare nurses for the DRG system." Educators in 50% (n=4) of the diploma, 22% (n=4) of the baccalaureate degree, and 9% (n=4) of the associate degree programs gave a "yes" response. The anticipated outcomes reported by four educators in baccalaureate programs include: "general awareness of the implications," "faculty recognition of course changes," "increased understanding of DRG." Diploma educators anticipated "better insight into acuity levels of patients," "...awareness of cost and cost reduction strategies." 67% (n=32) had not conducted "any type faculty development programs to prepare the undergraduate nurse educator." More of the diploma educators 34 (63% (n=8) than associate degree 81% (n-A) or baccalaureate degree 33% (n-6) gave a "yes" response. 85% of the educators (n=41) observed "an increase in the acuity of patients in clinical agency affiliations." According to 65% (n=31) of the educators patient teaching by students "increased" as a result of DRG. 60% (n=29) do not "utilize a Patient Classification System (PCS)...for the education of students"; 52% (na25) do not "coordinate the Patient Classification System (PCS) in student assignments." 90% (n=43) had not implemented "a formal Quality Assurance program as a result of the DRG System." Only 25% (n-Z) of the diploma programs gave a "yes" response. 83% (n-40) do not "have models of costing-out nursing that [they] teach students." Although 8% (n=4) of the educators gave a "yes" response, no specific model was identified. Three baccalaureate educators indicated "increased emphasis on economic implications" and discussion of the concept in a management course. 75% (n=36) have "developed collaborative arrangements between education and clinical agencies in which [they] maintain clinical affiliations." 81% (n—39) have not changed "the type and number of clinical affiliation agreements as a result of DRG." The six educators (13%) who reported 35 changes as a result of DRG "have to use more clinical settings," "added home health experiences," and [use] "more home care agencies or nursing homes." 59% (n-26) have not "developed a Management Information System (MIS)." A majority (50%/n-4) of the educators in diploma programs have either developed a Management Information System or are at an institution that is computerized. Fewer educators in associate degree (37%/n=7) and baccalaureate degree (29%/n-5) programs reported this type of experience. 83% (n=40) do not have "a program that prepares the consumer in your community for changes in the health care system." Of the 10% (n=5) who reported a program, more of the educators in diploma than degree programs checked "yes." Nursing was reportedly "involved with this consumer education" in 17% (n=8) of the programs. 60% (n-29) indicated the "institution's financial status as a result of DRG" was "unchanged." More of the educators in associate degree (73% /n-16) and baccalaureate degree (67%/n=12) programs gave this response . 90% (n=43) indicated their institutions had not "conducted any research related to the impact of DRG on [their] agency." Only 4% (n=2) reported research was being conducted. One educator did not have access to the research; another stated patient outcomes were compared with another hospital for selected DRG. 36 The educators were asked to "list five ways DRGs have affected your agency, and indicate if the result has been positive or negative." Examples of responses follow. Legit—hrs Increased focus on home care Emphasis on patient teaching, health maintenance, documentation, and quality assurance More challenging patient assignments Increased flexibility in faculty/staff sharing of responsibility for student learning Improved planning and assessments Better utilization of staff Negative Decreased census Decreased staffing patterns (resulting in less interactions with faculty and students) Increased paper work Early discharges Increased travel for faculty Employment of less educated nurses Time constraints on patient teaching Restrictions on student scheduling Sample The schools of nursing were selected through a random sampling of diploma, associate degree, and baccalaureate degree programs in 14 Southern states (Table 1). Collectively, the returns are from schools in 14 Southern states and represent a total of 603 full-time faculty. Most (45%) of the forms were completed by the nurse administrative head, i.e., dean, director, chairman. 37 TABLE 1 Sample Distribution Type Program Sample Returns [N-lOO] [N-48] Diploma 10% 17% Associate Degree 59% 46% Baccalaureate 31% 37% Instrument The tool, developed by Franklin A. Shaffer, Ed.D., R.N., Deputy Director, National League for Nursing, and used with the permission of Shirley Fondiller, Executive Director, Mid-Atlantic Regional Nursing Association, consisted of 31 items. Although most of the items could be answered with "yes" or "no," the survey contained eight open-ended questions. Table 2 provides information about the items that could be checked "yes" or "no", and the "yes" responses of nurse educators by type nursing program. 38 68 Table 2 "Yes" Responses to Selected Items by Type* Program D A B Total (n=8) [n-22] [n-18] [n-48] Has your institution adapted its curriculum to prepare nurses for the DRG system? 63% 64% 72% 67% Has your institution conducted any research related to the impact of DRGs on your agency? 25% —— —— 4% Has your agency conducted any type faculty development programs to prepare the undergraduate nurse educator in your facility? 63% 18% 33% 31% Did your agency implement a formal Quality Assurance program as a result the DRG system? 25% —— —— 4% Do you have models of costing-out nursing that you teach students? 13% -— 17% 8% Has patient teaching by students in your institution changed as a result of DRGs? Increased? 63% 68% 61% 65% Decreased? 5% 6% 4% No response 38% 27% 33% 31% As a result of the DRG system have you seen an increase in the acuity of patients in clinical agency affiliations? 88% 95% 72% 85% Do you utilize a Patient Classification System (PCS) in your institution for the education of students? 38% 27% 44% 35% Do you coordinate the Patient Classification System (PCS) in student assignments? 38% 41% 39% 40% Has your institution developed collaborative arrangements between education and clinical agencies in which you maintain clinical affiliations? 75% 77% 72% 75% Has your institution's type and number of clinical affiliation agreements 13% 9% 17% 13% changed as a result of the DRG system? 0V D A B Total _____________________________ ===___ ___==__________ [n=8] [n=22] [n=l8] [n=48] Has your institution been computerized or have you developed a Management Information System (MIS)? 50% 37% 29% 36% If yes, does the computer system or Management Information System (MIS) generate reports that include data specifically for the nursing department? 50% 23% 28% 29% Was nursing involved with the planning and implementation of the computerization of your agency? 63% 10% 28% 26% Does your institution have a program that prepares the consumer in your community for changes in the health care system? 38% 9% 5% 10% Is nursing involved with this consumer education? 38% 14% 11% 17% Has your institution’s financial status changed as a result of DRGs? Improved? 25% —— -— 4% Decreased? 13% 14% 6% 10% Unchanged? 13% 73% 67% 60% No response? 38% 14% 22% 21% Don't know 13% 6% 4% *D - Diploma program; A - Associate Degree Program; B - Baccalaureate Program THE IMPACT OF DRGS 0N CLINICAL NURSING CARE IN TERTIARY HOSPITAL SETTINGS Barbara A. Donaho Impact on Tertiary Hospitals Tertiary hospitals are those that have the professionals, facilities, and licensure for patients with the most complex illnesses. DRGs have had an even greater financial impact on these institutions than on the secondary community hospitals for several reasons. 1. The patients in tertiary hospitals have a greater severity of illness and require more complex care than those in the traditional community hospital setting. A higher severity of illness is more likely to occur in the elderly and indigent. Tertiary hospitals have a higher proportion of indigent and non-paying patients than most community hospitals. Community hospitals are minimizing their financial risks by referring additional patients with poor reimbursement to tertiary hospitals. The effect is an increased proportion of these high-cost, inadequately reimbursed patients in tertiary hospitals. Tertiary care hospitals are reimbursed the same fixed payment for a specific DRG as the community hospital, even though their patients are more likely to have a greater severity of illness. Tertiary care hospitals have higher costs because of advanced technology and equipment, specialized physicians and services, and higher patient acuities. 41 5. Tertiary hospitals participate in the expensive training and education of physicians and other health care professionals. Although Medicare provides an adjustment for medical education, the reimbursement is inadequate to cover the additional costs. 6. The high proportion of ICU beds to total beds in the tertiary setting further increases the financial risk under the DRG system. Galanes, Harris, Dulski, and Chamberlin (1986) reviewed 100 Medicare patients admitted to the Medical/Surgical ICU over a six-month period at the Michael Reese Hospital, Chicago. Only 6% of the study group yielded a profit to the hospital. Douglass, Rosen, Butler, and Bone (1987), in recent studies at Rush-Presbyterian--St. Luke's Medical Center, (Chicago) reviewed 95 non-surgical Medicare patients who were ventilator-dependent for more than 48 hours. After the researchers allocated the additional Medicare reimbursement that "covers" the increased costs of tertiary care at teaching hospitals (outlier reimbursement, the Medicare adjustments for indirect medical education, direct medical education expenses, and capital-related expenses), the average loss per discharge was $23,129 or $2.2 million (below costs) from July 1, 1983 through June 30, 1984. Gracey, Gillespie, Nobrege, Naessens, and Krishan (1987) reviewed 150 Medicare patients at three hospitals who were mechanically ventilated longer than 48 hours. The reimbursement on each of these patients averaged $20,915 each below costs for the 15 patients reviewed. Prior to the implementation of Medicare DRG—based reimbursement, hospitals traditionally compensated for their underpaying population by "cost shifting." 42 A traditional method of cost shifting is to proportionally increase charges for room rates, supplies, and ancillary charges to the other third payers that are reimbursing on a charge basis. Recently, state regulatory constraints (such as the Florida Hospital Cost Containment Board), commercial insurance and Blue Cross price constraints combined with insufficient per diem reimbursement by other state programs (Medicaid, Florida’s Children's Medical Services) have placed low ceilings on charge increases by hospitals. The result has been a decrease in the ability of the hospital to cost shift. Competitive pricing to attract a larger consumer base has further diminished the hospital's ability to cost shift and precipitated significant budget expense cuts within some hospitals to avoid negative net incomes. Arthur Andersen & Company and the American College of Healthcare Executives (1987) predicted that 10% of the nation's hospitals will close over the next eight years because of their inability to respond quickly to internal and external fiscal pressures and maintain the positive net income that is necessary for survival. The remaining hospitals will treat only the most acutely ill patients who require the most technologically advanced treatment. Hospitals have also responded to the fixed payment system of DRGs by discharging patients earlier, in order to decrease expenses. (The payment for a specific DRG is the same, regardless of the number of days a patient stays, so that profit margins are increased if length of stay is decreased.) The result has been a shorter length of stay and, thus, a higher intensity of services for the days the patients are hospitalized. Hospitals are further constrained by the boundaries imposed by utilization review, regulated by the federal Health Care Financing Association (HCFA), that determine whether or not the criteria have been met for Medicare 43 EXHIBIT 1 ACUTH 1985—1987 OCCUPANCY—RANKED BY HOURS INTENSIVE CARE N= 1 8 PERCENT OCCUPANCY -— MEAN ----- MEDIAN --------- 4TH QUARTILE --- 3RD QUARTILE _.. 2ND QUARTILE —"- 1 ST QUARTILE 68 l l 1985 1986 1987 EXHIBIT 2' ACUTH 1985—1987 OCCUPANCY—RANKED BY HOURS MEDICAL—SURGICAL N=18 PERCENT OCCUPANCY , as — MEAN as ----- MEDIAN 84 ooooooooo 4TH QUARTILE 82 _-. 3RD QUARTILE ao _.. 2ND OUARTILE 7a _... IST QUARTILE 7s 74 ' ' I 1985 1985 1987 reimbursement. HCFA and other third-party payers now require preadmission approval for some diagnoses for the hospital to be reimbursed. Outpatient approaches have replaced some of the traditional impatient surgical and diagnostic procedures. Empty beds have increased, and the average of stay has declined, precipitating a further reduction in revenue. Many hospitals cannot compensate by proportionally increasing the number of admissions to fill the empty beds and replace the loss revenue. Impact on Nursing The decline in average length of stay, the increase in referrals from other hospitals to tertiary centers (to avoid the fiscal risks of complex cases), and indigent and low—paying patients, have precipitated an increase in both census and acuity for many tertiary hospitals. A rising census coupled with an increasing acuity significantly escalates the demand for nursing services. The recent impact of the hospitalized AIDS population has also contributed to an increase in the nursing workload. The problem is further intensified by a shortage of nurses across the country that has not yet reached its peak. The perceived response of the tertiary hospital to a rapidly declining bottom line has been to stimulate nursing budget cuts. Data Occupancy Rate: ICU vs Non-ICU Beds A 1987 study by the Appalachian Council of University Teaching Hospitals (ACUTE) reviewed occupancy trends for 1985, 1986, and 1987. The study was limited by a defined two-week data collection period each year in the 18 member hospitals. The 8% growth (from 75% to 81%) in occupancy for intensive care units (see exhibit l) was over twice the 3.7% increase in occupancy for non-ICU medical/surgical nursing units (see exhibit 2). For the 13 hospitals with non—ICU pediatric patients, the occupancy declined by 6.5% (see exhibit 3) 45 while the occupancy in the 15 hospitals with pediatric and neonatal ICU's increased by 4.8% (see exhibit 4). Patient days--the sum of the occupied beds in a hospital for each day of the year--is a census indicator. Six comparable Florida tertiary hospitals are clustered in the same peer review group by the state's Hospital Cost Containment Board (HCCB). Data from the hospitals’ annual HCCB reports were analyzed by ICU and Non-ICU patient days. The six hospitals represented 290,197 ICU patient days or 265 average annual occupied ICU beds and 2,302,647 non-ICU patient days or 2,103 average annual occupied beds for the three years (FY 1984, 1985, 1986). Five of the six hospitals experienced an increase in ICU patient days (FY 1984-86, excluding newborns and NICU patients) ranging from 9% to 61.5%, or an ICU weighted average occupancy increase of 21% (see exhibit 5). One hospital experienced a 4% decline in ICU days. Three of the five hospitals that experienced a growth in ICU patient days had a decline in non-ICU patient days. One would expect that the percentage growth in demand for ICU beds would be consistent with the growth in demand for non-ICU beds if the acuity of the patients remained the same. The inverse relationship between the overall growth in ICU patient days and the decline in non-ICU patient days suggests that patients' acuity levels are increasing. While intensity figures imply appropriate use of the intensive care unit, further studies need to be done for the appropriateness of ICU utilization. Wagner, Knaus, and Draper (1983) have developed an Acute Physiology and Chronic Health Evaluation (APACHE) severity of illness classification system to measure the appropriateness of ICU admissions. One can predict that such a tool will be required by all hospitals to justify ICU care and reimbursement for each patient. 46 EXHIBIT 3 ACUTH 1985—1987 OCCUPANCY—RANKED BY HOURS PEDIATRIC N= 13 PERCENT OCCUPANCY 88 a4 80 76 72 68 64 60 56 EXHIBIT 4 —- MEAN ----- MEDIAN ......... 4TH QUARTILE - - . 3RD QUARTILE —'- 2ND QUARTILE ---- IST QUARTILE ACUTH 1985—1987 OCCUPANCY—RANKED BY HOURS PEDIATRIC INTENSIVE CARE PERCENT OCCUPANCY 100 96 92 88 84 80 76 72 1985 1986 1987 N=15 — MEAN ----- MEDIAN --------- 4TH QUARTILE --- 3RD QUARTILE —'- 2ND QUARTILE —"' IST QUARTILE EXFHBH 5 ICU VS. NON—ICU PATIENT DAYS AND ADMISSION ANALYSIS FISCAL YEARS 1984 - 1986 ICU & . ICU NON-4CU NON-4CU TOTAL PATIENT DAYSI ANALYSIS PATIENT DAYS ADMISSIONS ( 7: CHANGE) ( z CHANGE) COMBINED ( z CHANGE) HOSPITAL1 A 377. A 77; A 47:. A1127. HOSPITAL 2 A51.5z V 5.77, A 8% A 104% HOSPITAL 3 A 15% v 1% A2-57' A 9.57. HOSPITAL 4 V 4% ‘ Y 3.6% V 4.2% V 7.17; HOSPITALS A 97. A 1% A2.4*z A .27: HOSPITAL 6 A 17% V 16% V 7.8% V1227; “15295:? A 217; Y 3.8% A .37: CHANGE 1 - EXCLUDES NWU Acuity Analysis Acuity analysis across hospitals is a major challenge in health care. Most hospitals have or are implementing acuity systems to measure the nursing workload. There is no universally accepted patient classification tool (acuity system). Acuity systems provide a means of comparison for patient acuity levels and define the required nursing workload measures (e.g., hours of care) for each nursing unit within a hospital. A few acuity systems market their tool as valid and reliable across hospitals. However, because of hospitals’ unique internal differences that distort comparability, the comparisons are vulnerable to distortion. These differences include layout of physical space, 48 percentage of RN staff, nursing delivery method (primary care, team nursing, functional nursing, etc.), location of supplies, quality controls, clerical functions, transport team availability, and other variables. Attempts have been made by the American Hospital Association's Monitrend Reports (1984, 1985, 1986) and the Florida Hospital Cost Containment Board (1984, 1985. 1986) to measure several variables that have an impact on the nursing workload (acuity). The HCCB annual reports reflect laundry pounds, recovery room minutes, respiratory therapy treatments, blood bank volume, neurosurgery minutes, open-heart surgery minutes, pharmacy and central supply volume, and other parameters. Analysis of these variables for the six-member peer group of tertiary hospitals yielded no consistent relationship. This is probably due to the widely different counting methods at the various hospitals. For example, pharmacy and central supply items that generate a patient charge would be counted at one hospital but may not generate a charge at another and, thus, would not be counted. Recovery Room minutes vary across hospitals based on the number of hours a day the recovery room is open. Some hospitals utilize their recovery room overnight as a buffer to the surgical ICU, while other hospitals only staff the rec0very room for one or two shifts per day. Blood banks, laundries, and respiratory therapy departments also count their volume indicators in varying ways; hence cross comparability can be seriously distorted. Therefore, ancillary volumes and other indicators from HCCB data were found to be unsuitable as a proxy for nursing workload for the purpose of this study. An increase in acuity is supported by a model developed by hospital management engineers, D. J. Sullivan and Associates (1983), who have developed an acuity system that measures nursing workload in hours of required care. 49 Sullivan's model shows that prior to pre-admission testing and utilization review, the average hospital length of stay was nine days, and an average of 164 hours of care were required per day for a typical 40-bed unit (see exhibit 6). EXIHBH'S IMPACT OF MEDICARE REGULATIONS ON ACUITY ACUITY DURING HOSPITAL STAY HOURS CLASS- PRE- SURGCAL UHLQAUON 0F CARE HCAHON ADLHSflON PAHENT REWEW TESTING 15 -—-— 6 I I I I &5 —-—— 5 I I I | I 5.5 -—-— 4 I I I I i5 ———— 3 , I I I I 3.5 -——— 2 I I I I 25 —-—- 1 I I I | l I I I; 4 5 b 9 LENGTH OF STAY PRIOR TO PRE—ADMISSION WITH PRE—ADMISSION TESTING. UTILIZATION REVIEW TESTING. UTILIZATION REVIEW (9—DAY STAY) (5—DAY STAY) (ASSUME 40-BED UNH WHIIFULL CENSUS) (ASSUME 40-BED UN” WHIIFULL CENSUS) TOTAL HOURS OF CARE REQUIRED 36.5 TOTAL NURSHIG HOURS REQUIRED 25.5 AVERAGE HOURS OF CARE AVERAGE HOURS OF CARE REQUIRED PER DAY 4.1 REQUIRED PER DAY 5A AVERAGE HOURS OF CARE REQURED AVERAGE HOURS OF CARE REQURED PER DAY FOR 40—BED UNIT 164.0 PER DAY FOR 40-BED UIHT 204.0 AVERAGE NUMBER OF STAFF AVERAGE NUMBER OF STAFF REQUIRED FOR 40-BED UNIT 20.5 REQUIRED FOR 40—BED UNIT 25.5 With preadmission testing and utilization review (both required by HCFA for Medicare reimbursement and by other third-party payers as well), one and one—half days have been cut from the front and two and one-half days from the end of the typical nine-day stay. If one assumes the same mix of patients and census as before, the result is an average five-day stay, with the mean hours 50 of nursing care required per day for a typical 40-bed unit increased from 164 hours to 205 hours. The result is an increase of five full-time employees or a 25% increase in nursing staff to provide the additional hours of care. Connie Curan, Ph.D., American Hospital Association (AHA) Vice President for Nursing, stated that, "96% of the AHA hospitals surveyed report patient acuity has increased since April, 1986" (Health Professions Report, 1987, p. 4). The Impact of a Declining ALOS on Acuity The average length of stay (ALOS) is a hospital’s indicator of the bed turnover rate. The standard formula is the annual number of patient days divided by the annual number of admissions (or discharges). Has the ALOS in hospitals decreased? The American Hospital Association’s Monitrend Report for U.S. teaching hospitals (400—599 beds) has remained constant in the 7.31 to 7.32 level during the 3rd quarter comparison for 1984 and 1985 (see exhibit 7). For the third quarter 1986, the ALOS increased by 3% to 7.56 days. However, teaching hospitals in the Southeast U. S. experienced a decline in ALOS from 7.91 days in 1984 to 7.73 days in 1985, or 2.2% during the same period; from 1985 to 1986, however, the ALOS increased from 7.73 to 7.89 or 2.1%. The Florida HCCB comparison for the peer group of six tertiary hospitals experienced a decrease in the average length of stay, from 7.94 to 7.59 days, or 4.4% for the same three-year period. ALOS declined in three of the six Florida HCCB tertiary hospitals reviewed for the three-year period FY 84—86, and for four of the six for the two-year period FY 85-86. One could hypothesize that it takes longer for the complex tertiary care center to respond to external pressures to decrease the average length of stay or that the tertiary hospital is left with sicker patients after shifting a proportion of their own patients to outpatient facilities and getting additional patients from community hospitals. The turnaround to a 51 EXFHBH'7 HOSPITALS ALOS COMPARISON JUNE-NOV JUNE-NOV JUNE—NOV 1984 1985 1986 u.s. TEACHING 7.31 7.32 7.55 HOSPITALS (400-599 beds) (1) SE. TEACHING GROUP (1) 7.91 7.73 7.89 HCCB GROUP (2) 7.94. 7.62’ 7.59 SOURCE . DENOTES FULL YEAR DATA (1) MONITREND (AHA) (2) HCCB rising ALOS for both U. S. teaching hospitals and the Southeast U. S. teaching hospitals may be explained by rising acuity levels as a greater force than the pressures to decrease ALOS. Data are not available to review the ICU average length of stay from Monitrend or HCCB. With the increase in ICU patient days, an increase in overall hospital stay (ALOS) would be expected, because ICU patients normally are in the hospital longer. Galanes, Harris, Dulski, and Chamberlin (1986) stated that the average hospital length of stay for the general hospital population (non-obstetric) was 8 days with 22 days for patients receiving intensive care therapy (p. 518). The decreased ALOS coupled with the increase in ICU patient days suggests that patients are being moved out of the ICU to the non-ICU nursing units sooner and are being discharged from those units quicker, forcing an even higher acuity than that produced by preadmission testing and utilization review alone. The small sample size and lack of detailed data precludes the testing of any of these hypotheses. 52 As hospitals experienced a decrease in the ALOS, the number of admissions increased in five of the six Florida HCCB tertiary hospitals. Increases in admissions directly impact "total" patient acuity levels. The number of admissions had increased 10% for three of the six Florida HCCB tertiary hospitals. An increase in admissions also generates an increase in transfers between ICUs and non-ICUs. More admissions, transfers, and discharges increase the nursing workload. National engineered standards for average nursing workload at tertiary hospitals have been developed by Medco: ICUs Non-ICUs Unscheduled Admissions 79.2 min. 42 min. Discharges N/A 30 min. Transfers 41 min. 27 min. Therefore each unscheduled ICU admission that is later transferred to the floor and then discharged has an average impact of 2.95 hours (79.2 + 41 + 27 + 30 — 177.2 min.) on nursing care. A non-ICU admission that remains on the same unit throughout hospitalization has an average impact of 1.2 hours (42 + 30 - 72 min.) per patient. A patient that is admitted initially to a non-ICU unit (unscheduled) and is later transferred to ICU (i.e. post—operatively) has an average impact of 3.46 hours per patient (42 + 27 + 41 + 41 + 27 + 30 = 208 min.). Another method of measuring the growth in intensity levels at hospitals is through analysis of trends in operating revenues and operating expenses. Growth in operating revenue and expense growth are driven by four primary forces: 1) volume increases; 2) intensity increases; 3) price increases; and 4) changes in depreciation, interest, and deductions from revenue. The growth in operating expenses and revenues was analyzed by one Florida tertiary 53 teaching hospital for the years 1981 to 1987. Intensity attributed to revenue and expenses were determined by solving the equations: Intensity attributed to revenue - Total revenue (Revenue attributed to volume increases - revenue attributed to price increases.) Intensity attributed to expenses - Total expenses (Expenses attributed to volume increases - expenses attributed to price increases + expenses attributed to changes in depreciation, interest and deductions from revenue.) Intensity and volume were adjusted to 1979 dollars. The results showed a 621% growth in revenue and a 224% increase in expenses attributed to intensity (see exhibit 8). The revenue component due to intensity grew at a rate 2.77 times that of expenses due to intensity. One explanation is that the hospital is more productive--using less resources for a rising demand. Another explanation is that the labor provided has not increased in proportion to the demand for services. The key probably lies in a combination of these factors. The large difference in the revenues generated from increased intensity and the expenses that have been incurred does not mean that the hospital is experiencing a large margin of profitability. Rather, in order to keep pace with rising intensity, hospitals are having to commit substantial resources to new technologies and other capital assets that increase depreciation and interest expenses. These two major expenses, coupled with a growth in deductions from revenue because of lower third-party payer reimbursement rates, have rapidly eroded the hospital's margin of profitability. Nursing Labor Analysis Two primary parameters can be used to analyze nursing labor. One gross measurement is the number of full—time employees (FTEs). A more refined approach is RN hours worked per patient day. 54 EXHIBH'B REVENUE & EXPENSE GROWTH ATHNBUTED TOINTENSHY 1981 — 1987 (in 1979 dollars) DOLLARS 0n nfimons) so EXPENSES 50 — BEE OPERAHNG REVENUES 4o — t '9 O ( D O 30 — ' '3': '0’. 3:1 :o:« ~ ’9‘ "90‘ .7.- o c o o ’ ’0'. '3’... 2'“- ’o’c ’0’. 20 ~ -55: »% :1 '30: : r.-' D O ' 15¢£ 88 .791... a... 1 0 :-'.= :.:. '.::. . v .4, .0; - .0 ¢ 83 1984 1985 1986 1987 1. FISCAL YEAR ENDED JUNE 30 °5 The 1985-87 ACUTH study provided the only data available for RN hours worked per patient day. A limitation of the study is that data collection was confined to a comparable two-week period during the year at each of the 18 Southeastern tertiary teaching hospitals in the ACUTH group. iThe ACUTH trend analysis for non-pediatric and non-neonatal ICUs show a mean increase over the three-year period from 17.6 nursing hours per patient day to 20 hours per patient day, or an increase of 14% (see exhibit 9). Pediatric and Neonatal ICU experienced an average increase from 12.5 hours per patient day to 14 hours, or an increase of 12% (see exhibit 10). Non—ICU medical/surgical units had an average increase of 13.5% and non-ICU pediatric units an average increase of 13%. 55 EXHIBIT 9 ACUTH 1985—1987 NURSING HOURS RN HOURS 26 24 22 20 18 16 14 12 10 INTENSIVE CARE PER PT DAY _ — MEAN _ III-I MEDIAN ._. ‘.—— mums 4TH QUARTILE _-- 3RD QUARTILE _.. 2ND QUARTILE —--- 1ST QUARTILE 1985 1985 ‘987 YEARS EXHIBIT 10 ACUTH 1985—1987 NURSING HOURS PEDIATRIC INTENSIVE CARE N=15 RN HOU RS PER PT DAY 22 18* 16- I|\\||I|||l||||||||I\|||II|I|| I“ mm“ | ‘|l‘ II I —- MEAN ----- MEDIAN lllllllll 4TH QUARTILE - - - 3RD QUARTILE 14 — ' _ W 2ND QUARTILE 12 - z” _ ’I’ ma xsr QUARTILE 10 ~ ' .. 0’"— 8 _ —Il—lI—lI—ll—ll—II’II’..’-l’ 1985 1985 ‘937 YEARS Sherman (1987) polled 15 ACUTH Hospitals. Of those, 10 have acuity systems. All 10 acuity systems were in place prior to 1985 and define daily staffing needs. Under the assumption that the hospitals are using acuity as the "driver" for staffing, the data would suggest that acuity is increasing within both ICUs and the non-ICUs. However, when the hours per patient day for each unit are compared to changes in occupancy level, an inverse relationship is apparent: As the occupancy levels falls, the RN-worked hours per patient day rise, and vice versa. This implies that the hospitals have not been able to adjust their staffing according to the changes in occupancy or acuity. The FTE analysis of the six Florida HCCB tertiary hospitals supports this conclusion. Patient days in ICUs (excluding NICU) increased from 17% to 61.5% during the three fiscal years, 1984-86. One hospital experienced a 4% decline in patient days. The weighted average for increased patient days for the six hospitals was 21%. However, the number of ICU FTEs for these six hospitals increased by only 10.5%, or half the expected number driven by occupancy alone (see exhibit 11). The 10.5% increase could be caused by an improvement in productivity or an increase in unfilled budgeted positions. The six hospitals rapidly responded to a 3.8% decrease in non—ICU patient days during the same three fiscal years (1984-86). The number of non-ICU FTEs decreased by 4.5% (see exhibit 12), which suggests a rapid response to a declining occupancy rate and an inability to appropriately staff for rising acuity levels. Other Factors Impacting Staffing The six hospitals’ inability to respond to an increasing ICU occupancy rate may be triggered by the national nursing shortage that has not yet peaked. The national shortage of nursing has occurred for several reasons: 1) Enrollments in nursing programs in schools and colleges are rapidly decreasing because 57 EXHIBIT 1 1 ICU ANALYSIS FISCAL YEARS 1984/1986 COMPARISON OF % CHANGE IN PATIENT DAYS AND FTES PATIENT DAYS/FTES Z CHANGE 60- 50— 4o— 30— 20- 9o?- I...“ f. '0 .0 '0 .0. .0 .0. ‘0 10- o". O. 0.... are" H1 H2 H3 H4 H5 H6 AVG. HOSPITALS EXHIBIT 12 NON—ICU ANALYSIS FISCAL YEARS 1984/1986 COMPARISON OF % PATIENT DAYS/FTES z CHENIéIéNGE IN? PATIENT DAYS AND FTES 1O fl PATIENT DAYS W FI'ES (II I ' '0'0'6'0‘9‘6- .o,o.o.o.o.o O o H1 H2 H3 H4 H5 H6 AVG. HOSPITALS 58 women are choosing non—traditional career paths, such as engineering, business and law; 2) More nursing career opportunities are available outside the traditional hospital environment--insurance companies, ambulatory care centers, ambulatory surgical centers, utilization review, personnel agencies, home health care and alternative delivery systems (ADS); 3) Salary compression--engineers' and nurses' starting salaries are comparable, but in 20 years, the engineer makes more than double what the nurse earns. A nurse who works 15 years at the bedside only makes 50 cents more an hour than a nurse with five years' experience (Health Professions Report, 1987). Naisbett, (1982) states that newspaper headlines and ads are a predictor of present issues and future trends. A review of classified ads from various newspapers across the country shows a significant increase in space devoted to nurse recruitment. Salary increases have had the most significant impact on decreasing previous shortages of nurses. Salary increases are harder to sell to non-nursing hospital executives because of the fixed payment environment of DRGs and the associated fiscal risks of increasing expenses in a competitive health care environment. Yet wage wars are occurring across the country, driving up salaries, but the number of nursing positions are frequently decreased to compensate for the increased salaries. Turnover rates are increased by nurses moving to other hospitals before their hospitals can implement a salary response to the competing ads. Higher turnover rates cause higher costs for recruitment and, particularly in teaching hospitals, higher costs for orientation of the work force. Inexperienced graduate nurses are increasingly being hired by tertiary hospitals, and they require more hospital resources for their orientation and preparation for assuming a "full load" of patients. 59 Hospitals spend more than 60-90 days to recruit ICU nurses. More than 60 days are required to recruit medical/surgical (non-ICU) nurses. Labor Department statistics show that 10 days are required to recruit the average non—hospital worker (Health Professions Report, 1987). Compounding the shortage is the rapidly changing high-tech environment that is increasing the resources needed for the training and education needs of the nursing staff. Economies and efficiencies of cross-training are difficult and risky in a high—tech environment that promotes specialization. Curtin (1987) summarizes the challenge well: "The greatest problem is that nursing has become so highly specialized that it is extremely difficult to get the kind of nurses needed, where they are needed, when they are needed--and to keep them there once you do get them." (p. 7) When the number of available nurses are declining and the acuity of the patients are increasing, the major issues become improving the productivity of the current staff, retention, and quality of care. The challenge is to address these issues in the DRG environment of cost control. Improving Cost Control Cost control is an educational process and requires the commitment of additional resources to implement. The savings associated with the implementation should outweigh the allocation of the resources. The Department of Nursing and Patient Services can control costs by: 1) Development of mid-level nursing management fiscal skills, such as budget variance analysis, variable staffing based on acuity, and inventory management and control; 2) Implementation of acuity systems as a tool for management control; 3) Implementation of cost accounting for nursing services as a management tool; and 4) Participation in nursing research to improve quality, 60 explore more efficient systems of care, and safely decrease length of stay. The dilemma is that time is required for the staff to engage in research activities, but these resources are then diverted from direct patient care. Therefore research places an additional burden on the staff, yet it is a crucial activity. Cost control is also enhanced by improving nursing ’productivity. Improving Nursing Productivity If defined as direct patient care, productivity has been reduced because of the expansion in the documentation required for: l) Medicare-DRG and other third-party payer reimbursement; 2) Joint Commission on the Accreditation of Hospitals (JCAH) quality assurance requirements, and liability protection from malpractice suits. Institutional-wide productivity and the efficient use of resources are essential, to enable direct caregivers to use their professional skills appropriately. Productivity can be increased by creative management strategies: 1. Increase clerical support positions. 2. Decrease and streamline paper work. 3. Automate systems for sharing, care plans, staff scheduling (incorporating clinical competencies), and workload forecasting. 4. Adopt time-saving equipment design. 5. Provide productivity-engineered work stations. 6. Decrease errands (i.e. transporting lab Specimens) and off-unit time (transporting patients). 7. Avoid "burn-out." 8. Conduct nursing research as a means to determine cost-effective nursing intervention. 61 9. Determine appropriate utilization of nursing assistants and technicians. Increasing Retention The shortage of nurses, high costs, and lag time associated with recruitment, orientation, and preparing nurses to function in the complex hospital setting forces retention to be a primary goal. Career development programs, tuition reimbursement, scholarships, salary differentials, job sharing, partial shift employees at peak levels, flexible work schedules, positive feedback, rewards to nurses for contributions to patient care and professional recognition are effective strategies. Salaries must be competitive and must reward experience and professional expertise. The challenge for nursing management is to create a work environment for the employee that enhances self-esteem, values, career goals, and productivity. Quality Issues The external environment, rising patient acuity levels, the shortage of nurses, and internal constraints on costs all increase the risks of compromising quality. Hospital fiscal managers are using national data (although objective limitations have been identified) to compare staffing of other "comparable" hospitals to their own. Using data and staffing ratios at the bottom of "comparables" as pressure to minimize could compromise quality. Objective quality control systems are essential for identification of declining trends. Quality assurance mechanisms must be implemented promptly so that patient care is not jeopardized. Another primary issue in quality control and in a competitive environment is patient satisfaction. Concurrent surveys of patient satisfaction must be implemented and analyzed, with rapid and decisive follow-up, to identify and correct problems. 62 Conclusion The squeeze is on the entire health care industry. Nursing is in a pivotal position, where the pressure will be the greatest. The challenge is to find ways to effectively use all our resources while maintaining the critical role that nursing must assume. This must be accomplished without jeopardizing professional practice in nursing by diluting the kind of care given in an environment where the highest level of decision is required of professionals. If the issues and actions are not addressed successfully by the hospitals and the government, care will be compromised, beds will be closed, and patients will be denied access to care. 63 References Curtin, L. L. (1987). A shortage of nurses: Traditional approaches won't work this time (Editorial). Nursing Management, 18, 7-8. Douglass, P. S., Rosen, R. L., Butler, P. W., & Bone, R. C. (1987). DRG payment for long-term ventilator patients. Chest, 2;, 413-417. Florida Hospital Cost Containment Board. (1984, 1985, 1986). Annual Reports of Tertiary Peer Group. Tallahassee, Florida. Galanes, S., Harris, 3., Dulski, R., & Chamberlin, W. (1986). The intensive care unit population within the prospective payment scheme. Heart & Lung, 12, 515-520. Gracey, D. R., Gillespie, D., Nobrega, F., Naessens, J. M., & Krishan, I. (1987). Financial implications of prolonged ventilator care of medicare patients under prospective payment system. Chest, 21, 424—427. Health Professions Report (1987). lg, 4-6. Medco. Mr. Earl Wyvell. Engineered Nursing Time Studies. Personal communication, September 14, 1987. Melnick, F. & Sherman, J. (1984, 1985, 1986). The Appalachian Council of University Teaching Hospitals Annual Hours Report. Gainesville, Florida, Monitrend Quarterly Reports of the American Hospital Association. (1984, 1985, 1986). Naisbett, J. (1982). Megatrends. New York: Warner Books. Sherman, J. Personal communication, September, 1987, Gainesville, Florida. Sullivan, D. J. (1983). Cost-effective nursing productivity systems. Paper presented at the meeting of the Metropolitan Philadelphia Chapter of the Healthcare Financial Management Association and the Delaware Valley Hospital Management Systems Society, Philadelphia. Wagner, D. P. Knaus, W. & Draper, E. A. (1983). Statistical validation of a severity of illness index. American Journal of Public Health, 1;, 878-885. 64 REPORT OF A SURVEY ON THE IMPACT OF THE PROSPECTIVE PAYMENT SYSTEM ON NURSING PRACTICE WITH IMPLICATIONS FOR UNDERGRADUATE EDUCATION IN THE SOUTH Shirley J. Carey Purpose of the study was twofold: 1) to examine the impact of the Prospective Payment System (PPS) on clinical nursing in hospital and community settings in the Southern Region; and 2) to explore the implications of these changes in nursing care delivery on undergraduate nursing education. Methodology A mailed questionnaire developed by Frank Schaffer, EdD, RN (National League for Nursing) was used to collect information. Permission to use the questionnaire was granted by Shirley Fondiller, Executive Director, Mid-Atlantic Regional Nursing Association. Information requested in the questionnaire focused on the following areas: 1. Demographic Information: --Type of Agency --Bed Size --Length of Time under PPS 2. Computerized Management Information Systems: Use and Nursing Data Bases 3. Patient Classification Systems: Use in Resource Allocation 4. Staff Mix and Changes Resulting from PPS 5. Acuity, Length of Stay, Occupancy Rates 6. Discharge Planning, Patient Teaching, and Quality of Nursing Care 7. Costing Mechanisms 8. Patient and Staff Education Related to PPS 9. Impact of DRGs on Agencies 10. Implications for Nursing Undergraduate Education. 65 Sample Sample consisted of randomly selected hospitals situated in the 14-state* Southern Region. Of the 296 questionnaires distributed, 89 were returned in time to be included in this report. TABLE 1 Sample Representation Bed Size No. Responses No. Distributed % Returned Small 50 204 24.5% (50-199) Medium 23 59 38.9% (200-399) Large 16 33 48.4% (>400) 89 296 30.0% The majority of respondents completing the questionnaire indicated their title as Director of Nursing (48%), with Associate or Assistant Administrator (15%), or Vice-President of Nursing (16%) also indicated. *The 14 states are: Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, South Carolina, Tennessee, Texas, Virginia, and West Virginia. 66 All but three respondents described their institutions as acute care facilities. Therefore, because the information generated was mostly from acute care facilities, it does not reflect facilities for non-acute care. The majority of institutions (81%) had been functioning under prospective payment reimbursement since 1984 and about half of the institutions (n—45) now interact with other third—party payers who use a prospective reimbursement system. Management Information Systems Although most of the respondents (n—68) indicated that the hospital has a computerized management information system (MIS), only 36 (40%) indicated that nursing department data are included in reports generated by the system. Thirty—nine respondents indicated that nursing was involved in the MIS planning process; however, only 12% (n-ll) receive DRG-related reports on a regular basis. Six respondents indicated using the DRG reports in rescurce allocation decisions, and 16 indicated that DRG management reports were used with nursing audit data to evaluate efficiency. However, 30 respondents (35%) indicated that the nursing department was integrating its own productivity monitoring and human resources management systems. Patient Classification Systems Only 5 respondents indicated that they did not use a patient classification system within the nursing department, and 13 indicated that they did not incorporate the patient classification system with daily staffing allocations. However, many respondents indicated that they often lacked the number of nursing staff needed to match staffing with patient care needs. 67 Staff Mix The data related to staff mix indicated that 57% (n-51) of the agencies have changed their staff mix by increasing the number of licensed personnel (RNs and LPNs). Over 95% of the agencies reported having RN vacancies and 48% indicated LPN vacancies. The majority (80%) reported no nursing aide positions open. The distribution of RNs, LPNs, and nursing assistants is presented in Table 2. As the percentage figures presented in Table 2 indicate, the majority of hospitals in the study reported a staff mix of greater than 50% RNs and less than 40% LPNs. Twenty-four hospitals reported that over 70% of their nursing staff consisted of RNs. At least 15 hospitals (18.7%) did not report nursing assistant positions (note that 9 respondents did not answer this question). Although 48.6% (n-34) reported an increase in the number of RN positions, 35 hospitals (50%) indicated no change in the number of RN positions. Eleven hospitals (21.6%) reported increases in the number of LPN positions and only 5 (9.8%) reported a decrease in the number of LPN positions. Most respondents (63.7%) reported no change in the number of nursing assistant positions. The data clearly indicate that hospitals in the study have increased the number of licensed personnel positions and that staff positions remain unfilled. These data were collected in late August (1987) and suggest that the influx of new graduates did not meet identified needs. Acuitv. Length of Stay. and Occupancv Rates All but two respondents (both in small hospitals) indicated that their patient acuity had increased as a result of the PPS (DRGs). However, 41% (n=36) indicated that staff mix ratio changes were not directly related to the PPS (20 small, 10 medium, and 6 large hospitals). 68 TABLE 2 Staff Mix Presented by Hospital Bed Capacity Small Medium Large Total Percent of RNs (50-199) (200-399) (>400) % < 49 19 9 4 35.9 50-59 18 9 6 37.0 > 70 _13_ 4 __6_ $5.; TOTAL 50 23 16 99.8 Percent of LPNs < 40 23 18 12 59.5 > 40 A _5 _4_ 40.4 TOTAL 50 23 16 99.9 Percent of Nursing Aides O 11 2 2 18.7 <15 18 8 8 . 42.5 16-25 5 7 4 20.0 26-40 8 3 1 15.0 50-53 _L _L _0 A TOTAL 44 21 15 100 . 0 69 Most respondents (93%) indicated a decrease in average length of stay (LOS). The range of decrease was wide (.2 to 6.0 days) with most responses (n-4l) ranging from .5 to 2.0 days. Fourteen institutions indicated a trend for LOS to increase, particularly during the last year. The trend toward increased length of stay was reported by seven small, six medium, and one large hospital. Only three respondents indicated no change in LOS. As might be expected with shorter lengths of stay, occupancy rates were also noted to decrease. Only 17 hospitals reported increased or unchanged occupancy rates. Discharge Planning, Patient Teaching. and Quality of Nursing Care The majority (91%) of respondents indicated that their agencies have a formal discharge planning procedure. The social service department (26%), nursing department (19%), nursing department and social service depart- ments (34%), or a combination of nursing, social service, and home care agencies (9%) were responsible for the procedure. In 37% of the agencies, nursing was not involved in the discharge planning process. Most agencies (59%) indicated that the discharge planning procedure was in place prior to the implementation of PPS, but that the new legislation had increased the need for or importance of discharge planning. Similarly, the majority of respondents (79%) indicated having a Quality Assurance (QA) program and that these were in place prior to DRGs. The majority (60%) indicated that nursing was responsible for the QA program and only 25% indicated having a separate QA department. Although most respondents noted that patient teaching by nurses had increased since the implementation of DRGs, many indicated that staffing levels influenced the amount of teaching that nursing could provide. In addition, many respondents indicated that the need to document teaching had 70 perhaps strongly influenced the increases noted. Many respondents suggested that the shorter lengths of stay acted as a barrier to adequate patient teaching. Some respondents indicated that early discharge and increased acuity inhibited patient learning. However, a few respondents described innovative mechanisms that linked bedside teaching to discharge planning and community service follow-up of teaching plans. In general, the patient teaching plan focused on self—care and readiness for discharge. Some trend toward increased use of patient educators or expansion of the education department functioning was noted. Views related to the quality of nursing care being provided were overwhelmingly positive. Most respondents applauded their nurse' ability to maintain quality. Many respondents indicated an increase in nursing care hours per patient day and more appropriate setting of priorities. A small number (12%) indicated a lowering of quality. Of these, most noted a lack of staff or staff time to deal with patient needs. Of particular concern was the decrease in "caring" behaviors. A few respondents indicated that the quality of care had increased as more professional staff were hired and the number of nursing hours provided per patient day increased. They also noted an increase in discharge planning and increased utilization of home care referrals and follow-up as indicators of increased continuity of care. In conjunction with the quality question, many respondents cited problems with staff morale, burnout, and stress. The increased workload placed on nursing was highly recognized by respondents concerned about the increased skill and competence required in most nursing areas. 71 Costing Mechanisms The majority (86%) indicated that they were not currently "costing out" nursing care. A few respondents (n-l9) indicated that a plan for costing was being developed; however, only 10 of these indicated that the plan would link the patient classification system with resource utilization. Most (67%) noted a decrease in the financial status of their agencies, while 11% noted an increase and 22% reported no change. Patient and Staff Education Related to PPS Only 20 respondents indicated that their facilities have a program to prepare consumers for changes in the health care system. Most who noted a consumer education program indicated that nursing participates in the community-based program. The majority of respondents indicated that there had been inservice education and workshops for staff related to the PPS and its impact on health care. However, many indicated that the programs had not adequately prepared nursing staff for the rapidity of changes which occurred. Impact of DRGs on Agencies Both positive and negative outcomes of the PPS were identified by the respondents. The findings* are summarized below: Positive 1. Increased focus on efficiency and productivity. 2. Team building with more positive interactions between all departments and physicians. *The ordering of findings does not reflect establishing priorities for outcomes identified by the respondents. 72 10. Increased discharge planning and use of outpatient facilities (thus decreasing unnecessary admissions). . Expanded services: home health care and skilled care services, one-day surgeries, out-patient surgery. . Personnel more aware of costs and productivity problems. . More effective utilization review. . Nurses more effective and efficient and involved in discharge planning. Increased quality of patient care (related to increased numbers of RN positions, increased quality of staff, increased patient education and involvement of families, and increased continuity through discharge planning). Increased need for sound financial management and awareness of hospital needs. Development of short stay programs. Negative . Decreased length of patient stay with resulting loss of revenue. Increased acuity creating need for increased nursing staff, increased stress on personnel, increased paperwork, and lowering of quality standards. Increased conflicts between hospital administration, employees, physicians, and families resulting in a lowering (negative) community perception of the agency. . Increased need for management information systems which are not available. Increased financial and legal liabilities. Increased financial risk with loss of contracts, slow cash flow, denial of claims, and increased indigent care. 73 7. Less satisfaction with services on part of families and patients. 8. Increased need for linkages with other agencies in a highly competitive environment. Nursing Education Of those reporting that they have student nurses affiliating in their agencies, 3 indicated having diploma students, 53 had associate degree students, and 39 had BSN students. Although many respondents indicated no apparent changes in the student nurse learning experiences, many noted both positive and negative outcomes of the PPS. These findings are summarized below: Positive 1. Students have increased opportunities for assessment, teaching, and emotional support (because patient needs are more complex). *2. Increased acuity of patients enhances how students can be integrated within the system early in the educational process. 3. Students have increased opportunities to interact with primarily professional nursing staff and good role models. *4. Students have increased responsibility for care. 5. Students see a more realistic view of professional nursing (less reality shock). 6. Students are really needed and appreciated for their contribution to patient care. 7. Students learn first hand the financial constraints and concerns of both agencies and patients. *Items on which some respondents placed a positive value while others defined them as negative. 74 mm 1. Decreased census lessens the learning opportunities. 2. Decreased LOS puts pressure on patient learning needs which students may not be ready to handle effectively. 3. Increased staff workloads may have a negative impact on staff—student relationships. 4. Limited opportunities to pre-plan learning experiences. 5. Students lack understanding of PPS and how it influences quality of care issues as well as staff attitudes. 6. Students not prepared to handle the complexity of care required. 7. Some BSN programs too "wellness oriented," which leads to students having negative experiences in acute care settings. Some respondents offered additional comments directed toward nursing education: 1. Students need to be involved in discharge planning so that they can participate fully as new graduates. 2. There will be increased pressure on new graduates to be capable and competent quicker. 3. There is a need for longer orientation time, but agencies are pressing new graduates to perform quickly. 4. Student experiences are viewed by nursing administration as a great opportunity for staff recruitment. 5. We have had to drop our intern program because of excessive cost and feel new graduates will be the losers. 6 . We hope faculty include more extensive content on ethics, values, cost containment, and patient/family expectations and the nurses's role in helping patients toward self-care goals. 75 Although not DRG-related, respondents viewed positively the increase in joint hospital/education endeavors, including increases in scholarship and loan programs and the increased use by affiliating schools. Conclusions This survey of hospitals in the Southern Region clearly indicates that the prospective payment system has influenced nursing both positively and negatively. The increased acuity of patients and decreased length of stay have resulted in the need for more licensed nursing personnel and have placed increasing pressure on nursing to adequately prepare patients for discharge. Cooperation between departments appears to have increased, particularly in the areas of financial control and discharge planning. Most respondents indicated that the quality of nursing care has increased and relate this conclusion to the increased number of nursing care hours provided. Negative outcomes focused on financial concerns and interpersonnel conflicts which place hospitals in a negative light. Some hospitals were responding to expressed community concerns by providing education programs for consumers relating to the changes demanded by the prospective payment system. The impact on nursing education and students also had positive and negative implications. Many respondents indicated that student nurses have increased opportunities to observe good role models and to experience first hand the reality of professional nursing practice. Others expressed concern about the complexity of skill required and the fact that many hospitals can no longer provide extensive training programs for new graduates. Concern about increased staff workloads and the negative impact on staff-student relationships were also expressed. 76 THE IMPACT OF DRGs 0N NURSING CARE IN COMMUNITY SETTINGS Judith Baigis Smith Introduction Since 1965, the federal government has been responsible for paying for the medical care of people 65 and over under Medicare. An important issue then, is what constitutes "paying for the care." Until 1983, paying for care meant that the agency responsible for administering the Medicare health insurance program, the Health Care Finance Administration (HCFA), reimbursed providers, like hospitals and home health agencies retrospectively. In other words, what the providers charged for the covered services was what HCFA paid. But that method of reimbursement got too expensive for the federal government and another system, a prospective payment system, was implemented by HCFA in 1983 to decrease the Medicare costs from acute care hospitals. That hospitals were selected to test the prospective payment system is not surprising, since hospitals are paid more than two-thirds of the dollars that Medicare spends for personal health care (Waldo & Lzenby, 1984). HCFA adopted the Diagnosis Related Groups (DRGs) classification system as the method it would use to pay acute care hospitals prospectively for the care they provided to Medicare beneficiaries. The DRG system was chosen because, according to one of its developers, it was the only system available at the time (Thompson & Diers, 1985). DRGs list patient diagnoses with corresponding rates set by Medicare. These rates are calculated from national averages of treating Medicare patients and are based on patterns of resource use and lengths of stay (Balinsky & Starkman, 1987). Within this structure, then if 77 hospitals can effectively treat and then discharge their patients sooner than they did in pre-DRG days, i.e. if they can reduce their patients’ lengths of stay, they can keep the difference between the cost of a person's care and the Medicare rate set for that person's diagnosis. But hospitals are not freeto determine when patients should be discharged based on what they want their profit margins to be. Such behavior is mediated by strict malpractice regulations and Professional Review Organizations (PROS). So hospitals need to act responsibly when releasing their patients earlier, for these patients still need supportive services in less expensive settings, like their homes. The success of early discharge--patients who can receive appropriate care outside of the hospital and not return because of exacerbations or complications—~depends very heavily on the availability of a broad range of high quality home care services (McCleary & Driscoll, 1984). Hospitals have been utilizing the services of the home health care agencies to provide those supportive services. It must be noted, however, that what the patient needs is not always recognized by health care professionals. If these needs are recognized, the necessary resources are not always available. While nurses practice in many different types of community settings—-health departments, community health centers, for example—-it is the home health care agency and, consequently, the home health care nurse, visiting nurse, and public health nurse whose department also delivers home health services, who have borne the brunt of the acute care hospitals' practice toward increasingly earlier discharge of their Medicare patients. Nurses are the foundation of the entire home health care industry in this country. This paper will present background information on home care, the impact of DRGs on home care and the home health care nurse, the reactions of selected home care trade organization representatives and administrators of home health 78 agencies in the Southern Regional Education Board (SREB) region to the effects of the DRG system on the home care industry in their states, and recommendations for nursing education. Home Health Care What is it? Home health care is one of the many community-based industries or services that constitutes one part of the long-term care system in this country. It has been described as the "no overhead hospital" or the "hospital without walls." It is a type of health care which can be appropriate for any age group and for a wide range of medical and functional conditions: physically and mentally disabled children and adults; home-bound infirm elderly; people recovering from surgery, heart attacks, strokes, or injuries; or the terminally ill (National Consumers League, 1986). Thus, the phrase "home care" is used in two ways: to refer to the range of in-home services provided to chronically ill people over a long period of time; and it also refers to the Medicare-reimbursed home-based services which are primarily for the acutely ill elderly and which are skilled, short-term, intermittent (Meyer, 1986). This latter use is central to this paper. Historical Overview The visiting nurse associations (VNAs), our country's first major deliverers of home health care, originated in the latter part of the 19th century to send trained nurses into the homes of the sick poor. The health officers of the local health departments also added nurses to their staffs in the early part of the 20th century to do similar work. Hospital-based home care programs arose after the successful implementation of Montefiore Hospital's model of 1947. Patients discharged from that institution were entitled to a wide range of nursing, social, medical, and other related 79 services delivered in their homes (Cherkasky, 1949). By 1963, two years before the passage of Medicare, there were 1,163 home care agencies in this country, with 141 of them offering at least one other service besides nursing (National Association for Home Care, 1987). Most of their services were paid for by donations via organizations like the local community chests, by the recipients of the care, or in the case of some services, through the health departments, with tax dollars. Medicare and Home Care The passage of Medicare in 1965 changed home health care practices considerably. Medicare had three important consequences for the home health care industry and its major practitioners, the nurses. It ensured a secure reimbursement source for the services covered under the program and stimulated growth in the industry; it institutionalized the role of nursing in home care; and it shaped nursing practice. To be reimbursed by Medicare, a home health care agency must be certified. To become certified, the agency has to meet federal requirements and is monitored by the state health department on behalf of the federal government. Because of the dependable reimbursement source, increasing numbers of agencies sought, and obtained, certification. They also grew in numbers——l,753 in March 1966; 5,877 in August 1987 (National Associate for Home Care, 1987). See Table 1 for the number of Medicare certified home health agencies by state in the SREB region for December 1980, December 1983, and July 1986. By 1983, the first year of the DRG system in acute care hospitals, Medicare funds accounted for at least 70% of a home health care agency's revenues (Mundinger, 1983). In fiscal year 1985, Medicare paid for about $1.7 billion in home health care services (United States General Accounting Office, 1986). 80 TABLE 1 Number of Medicare Certified Home Health Agencies by State for the SREB RegionI December 1980I December 1983I July 1986. State Dec. 1980 Dec. 1983 July 1986 Alabama 92 106 124 Arkansas 95 155 155 Florida 132 141 177 Georgia 66 70 73 Kentucky 54 53 96 Louisiana 80 91 172 Maryland 39 68 96 Mississippi 134 135 135 North Carolina 87 99 115 South Carolina 27 36 44 Tennessee 146 212 343 Texas 85 341 487 Virginia 55 79 156 West Virginia 31 31 51 Note. Adapted from Basic Statistics on Home Care, August 1987 (National Association for Home Care) and personal conversation, Robert Hoyer, Research Director, National Association for Home Care, Washington, D.C. October 27, 1987. 81 The Medicare Conditions of Participation for Home Health Agencies define a home health agency as "a public agency or private organization...primarily engaged in providing skilled nursing services and other therapeutic services" such as physical therapy, speech therapy, occupational therapy, and home health aides (Federal Register, 1968 and 1973). Thus, for this entitlement program, nursing is central for reimbursement and for service delivery. But there is a price for this. Home health care is the one area in which nursing practice has been molded by Medicare policies. For example, nurses have been the case managers in home care. They have decided what services the patient needs and how often they are needed. This has been done within the constraints of the regulations, even when those regulations have contradicted nursing judgments. In summary, any significant change in Medicare policy will affect the majority of home care patients and, therefore, is likely to have a significant impact on the home care industry and the home health care nurse (Balinsky & Starkman, 1987). Medicare is, after all, the major purchaser of home health care services. Reasons for Growth Nationwide--and prior to the DRG system-—there has been a steady growth of the home care industry in numbers of agencies, in the demand for services, and in the numbers of visits made. The reasons for this must be understood in order to put in perspective the impact of the DRG system on home care. The numbers of people over 65 who are entitled to the Medicare home care benefit have risen. The use of professional review organizations (PROS) has shortened hospital stays and increased the use of less expensive out-of—hospital services. Changes in medical techniques and practices have increased the use of outpatient surgery with patients discharged to home care. Increasing numbers of private insurance companies are issuing policies to their 82 beneficiaries which include coverage for selected home care services as less expensive alternatives to hospitalization. And, improvements in medical technology have made home treatment possible where previously hospitalization was required. Techniques now adapted for home use include renal dialysis; intravenous lines, both central and peripheral, for the administration of parenteral nutrition, chemotherapy, antibiotics, narcotics, and sometimes, cardiac pressor agents; ventilator and apnea monitoring, especially used for children; skeletal traction and other rehabilitative aids (Koren, 1986). The Context for DRGs The legislative history of Medicare includes many amendments during its first 20 years. The amendments of the 20-year period reflect the concern of Congress for ensuring access to services, quality and appropriateness of services, and cost containment. ...the more recent amendments have focused on the issues of cost control and the need to broaden the revenue base. These efforts are evidenced by the increase in the hospital deductible from $40 in 1967 to $400 in 1985; the increase in the Social Security deduction wage base from $4800 in 1965 to $15,300 in 1976 to $37,800 in 1985;...; a freeze on physician fees; and finally, a new hospital reimbursement system based on prospectively set rates (Balinsky & Starkman, 1987, 62-63). The Impact of DRGs on Home Care Because home health care services were expanding before the institution of the DRG system, determining their incremental impact "will involve fairly complex analysis" (General Accounting Office cited in Balinsky & Starkman, 1987). The greatest growth has been in the number of free-standing proprietary agencies, hospital-based home care units, and free-standing chain-based 83 proprietary agencies which accounted for a total of 75% of the new agencies (647 of 866) between October 1983 through September 1985 (Balinsky & Starkman, 1987). While VNAs and government agencies are now relatively less numerous than the other types of agencies, they remain important players because they employed, in 1986, 41% of the full-time—equivalent people working in certified home health agencies (National Association for Home Care, 1987). In 1984, a study of 335 non-profit and public community-based providers from 32 communities in eight states reported that those providers were seeing older and sicker patients since prospective payment (General Accounting Office, 1986). Generally, these patients had more extensive service needs which required more frequent visits, and more need for highly skilled services. Kornblatt, Fisher, and MacMillan (1985) reported similar results in their Virginia-based research. Many agencies have responded to these needs by making the initial visits in less than 24 hours, by having 24-hour on-call services by nurses for emergencies, and by providing 7-day-per—week coverage by more highly skilled technical and clinical personnel, including but not limited to nurses. The federal government has not tried to cap hospital costs, only to have those costs show up in home health care. One result is that the fiscal intermediaries, acting for HCFA, have increased the number of retroactive denials of payment for services already delivered to home health care patients. Such decisions are creating cash flow problems and confusion in a number of agencies in the SREB region about who can now be served and covered under the Medicare home care benefit. At this point, it is instructive to note that the home health care industry is reimbursed retrospectively by Medicare on a cost-per-visit basis and the industry, unlike the hospitals, is not rewarded for efficiency. For example, if a home care agency is able to deliver services at a lower cost than in previous years, Medicare lowers the cost-per-visit reimbursement to that agency. 84 Comments from Home Care Professionals in the SREB Region Twelve home health care representatives in 10 of the 14 SREB states were telephoned in September 1987 and were asked to comment on the impact of DRGs on home care in their states, the major issues facing them, and the situation of the nurses in home care. Their responses follow. 1. Madge Helm. Administrative Assistant. Arkansas Association of Home Health Agencies. The prospective payment system based on DRGs has affected home health care in the state in two ways: (a) the hospitals, most of which are in rural areas, have been discharging their patients to home health agencies sooner than before this system was in place, and (b) rural hospitals are closing in increasing numbers, leaving the home health agencies to provide the needed care. Soon, she thinks, home health care will be the only care available in certain areas of the state. In short, the prospective payment system has forced an increase in the numbers of home health agencies there. Her worry is that only one system will evolve: one where people will pay for the services they need. People who cannot pay will not get the services. At present, she thinks that there is an adequate number of home health agencies in Arkansas because the state has a good health planning system which monitors home health care. It was through the state health planning system that guidelines and procedures on the expansion of home health agencies have been developed and implemented. She also thinks that the nursing care in home health is adequate. There is no shortage of nurses in the field. They like 85 their work and the Association has many training sessions for them so that she feels they are prepared for the type of practice they face in home care. 2. Marilyn ShifferdI Executive DirectorI VNA of Palm BeachI Florida. While their agency was growing prior to DRGs because of the population growth in the area, after the implementation of the DRG system, they saw a 30-40% increase in their growth pattern. The agency then experienced a dramatic drop in numbers served when Medicare adopted a different view of the home care benefit and increased its denials and when other providers entered the home care field like HMOs (the pilot programs for this were developed in Florida) and the hospitals. The agency has responded to these challenges by, among other things, preparing to deliver other kinds of services that are needed in the community, such as dental care, maternal-child care, worker's compensation care, and affiliating with the VNA of Florida group for joint services. The nursing staff, therefore, must know the latest on rules and regulations. (There are in-service programs for this). They must be highly skilled clinicians, be able to do good patient assessments, know how to use community services and resources. 3. Kathy AlexanderI Executive DirectorI Georgia Association of Home Health Agencies. Because of the prospective payment system, small hospitals in the state that are not keeping their beds filled are in financial trouble. Consequently, they are starting home health agencies as a way to shift costs and, thereby, stay afloat. This is a problem for home care because such tactics just delay the hospitals' closings. 86 One of the major issues in the state is that of home health aides. The Association needs to work on training packages for them so that current home health aides can be recertified and new ones can have a standard training procedure. A second issue is created by Georgia's Community Care Services Program, which is not managed consistently in the state. The Association has a contract with the state Medicaid agency to provide home health aides, personal care services, and respite services to those who qualify. They need to develop clear criteria for the home health aides and the homemakers. 4. Margie Mills, RN, President, Georgia Association of Home Health Agencies. Due to the DRG system, increasing numbers of people are coming home from the hospitals in ambulances. The patients' conditions require that nurses have "high tech" skills so, agencies are recruiting them out of hospital intensive care units (ICUs) and critical care units (CCUs). But there is a nursing shortage in Georgia so the service problems are compounded. The agencies in Georgia are adjusting to the federal regulations, but where there were agencies that used to get 100% of their income from Medicare, increasing numbers are serving people with private insurance. In view of this, Georgia needs and does have a very good Medicaid program. There are still nurses in management positions in home care because of the Medicare articles of participation, but increasing numbers of business people are now in home care. 87 5. Nileen Verbeten, Executive DirectorI Kentucky Home Health Association. After the passage of Medicare in 1965, there was an increase in the number of home health agencies in Kentucky. By 1974, all the home health agencies were covered by license and certificate, and there was no further growth until 1982. In that year, the state health plan called for tripling home care in three years (via FTEs rather than by number of agencies) and putting a moratorium on further nursing home expansion. Capital which would have gone into nursing homes was put into home care instead, since the state plan opened the door to anyone willing to try it. DRGs also increased the demand for home care. During 1983-84, the existing home care agencies increased their caseloads by 20% per year. This increase, though, was not in the number of Medicare patients above the usual ratio, but an increase of those with private insurance. It seems that once the Kentucky hospitals changed their practice pattern, they did it across the board, not just with Medicare patients. There was a shortened length of stay for all hospital patients. A number of agencies in areas with adequate population are adding teams who can deliver specialized services to patients, such as IV services. Such practices, however, may be due to the ability to deliver these high technology services in the home, rather than to the impact of DRGs. The denial rates by their fiscal intermediary increased substantially so that for one month last year it reached 34%. The denials were so erratic that the agency administrators did not know whom they could accept as patients. The Association responded by "declaring war on Medicare." They videotaped patients 88 served by agencies that had been denied payment and played the tape for the Congressmen in their state. Shortly after that, the denial rates dropped to zero. Ms. Verbeten does not know whether the drop in denials was due to the aforementioned strategy or to agency caution in serving patients. The major issues for the Association include: (a) focusing on appropriate education for staff; (The current agency practice regarding nursing, for example, is to recruit new staff from hospital ICUs because of the increased acuity level of patients.) (b) continuing to build a good relationship with the new fiscal intermediary; (c) implementing the Medicaid Waiver Program in home care; (This statewide program, effective July 1987, emphasizes the long-term home care and is seen as equivalent to services now rendered in intermediate care facilities. Home health personnel are being educated to deal with the chronically ill along with the acutely ill.) (d) lobbying for Medicaid coverage for routine postnatal home care since Kentucky has one of the worst infant mortality rates in the country. Ms. Verbeten observes that there is a slow but sure shift to. non-nurse administrators in the larger home health agencies in the state. For example, the only VNA in the state hired a non-nurse manager for the first time in its 97-year history. The smaller agencies are still reluctant to do this. Many of the home health staff nurses are graduates of associate degree programs so they have no formal education in management or in abstract thinking. 89 6. Robin DriscollI Executive DirectorI Maryland Association for Home Care. Maryland, like New Jersey and Massachusetts, has a cost review commission for hospital rates so that state is not affected by the DRG system. Since there is a cap on expenditures, the trend is to discharge patients early. The state also has a very strong certificate of need (CON) law which initially had a window in it whereby hospitals could open home health agencies after a review. This window was closed two years ago, but before that happened over 30 new agencies opened. Now, the biggest providers apart from the VNAs are the hospitals; and the VNAs are having problems because the hospitals are keeping their referrals. The health department has gotten out of the home care business. The length of stay (LOS) is down drastically in home care since Medicare has gotten narrow and specific in what it will pay for. 7. Gary Bowers. Executive Director. North Carolina Home Care Association. Home care was growing at the rate of 5-6% per year in the number of patients seen prior to the DRGs. There was a 23% increase in the numbers of patients in the first year of the DRGs; since then growth has leveled off to 5-6% per year again, but this growth is built on that 1983 spurt. That has not been lost. The nurses have to provide a more intensive level of care than they did five years ago and Medicare is becoming increasingly restrictive in what it will pay for. This is putting tremendous pressure on the practitioners. On the one hand, they are seeing sicker patients who require more visits and more time per visit; 90 on the other, cost-conscious administrators are trying to maintain or increase the number of visits per nurse per day. 8. Eleanor DurhamI RN, Director of EducationI North Carolina Home Care Association. Nurses in home care are doing much that is not traditional nursing care and are under pressure to do things for which they are not prepared. They do not, for example, understand the insurance system, including Medicare and Medicaid, or the coding systems, and they do not know how to set treatment priorities in the home. In addition, the conditions of their patients are so much more complicated that the policies and procedures for delivering the needed care are still being developed. In short, the limitations for delivering high quality, high technology home care are still being explored. 9. Gayle SasserI Executive Director, Tennessee Association for Home Health. Home health care services were delivered initially via the public health system in the state. With the advent of Medicare reimbursement, and while there was not a certificate of need program in the state, an increase occurred in the number and types of home health agencies. Now there is a mix of public, private, voluntary, proprietary, and hospital—based home care programs in the state, along with one visiting nurse association. There is also a trend for the public health system to withdraw from home care service delivery since the private sector is expanding. Home health care is booming in the state, that is, the industry is growing not in numbers, but in developing services that can be 91 safely delivered in the home. While Tennessee was first in the nation for several years in the number of licensed home health agencies, the state is trying to level this out. There is now a lot of merging among agencies, with ownership changes and diversification. With the DRGs, Ms. Sasser has observed that there is an increased emphasis on the delivery of skilled, high technology services in the home. The home health nurse has to be multi-talented. Since the practice is so independent, the nurse's judgment and assessment skills must be excellent. There is a problem in recruiting skilled nurses, physical therapists, occupational therapists, and speech therapists. She sees an increase in the number of private pay patients and in private insurance that will pay for home care. An increase in such trends should lead to a decrease in the amount of paperwork for the nurses whom, she feels, are spending too much of their time documenting the kinds of services given so that their agencies will be reimbursed for services. While the elderly have been the major category of patients seen in home care, this may not be true in the future. The agencies are delivering services to, for example, pediatric patients and worker compensation cases. The nurses have been the ones responsible for identifying the services that can be safely delivered in the home. Ms. Sasser's role is to promote the home care concept. Within that context, she is lobbying for national legislation that would expand the Medicare benefit to include long-term care. She is also working with the state Medicaid Bureau to expand home care to people receiving that benefit, such as AIDS and Alzheimer's patients. In conjunction with these efforts, the Association wants to develop 92 quality assurance measures so that the regulators can be Sure that patients are being cared for safely in their homes. One of her concerns is the number of unlicensed businesses which are developing services for the home with no regard for quality assurance measures. 10. Ron Waters, Executive Director, Texas Association of Home Health Agencies. The home health industry had been growing in Texas prior to 1983. Several factors were responsible for this growth, which enhanced the impact of the DRG system. Prior to 1981, the industry was heavily regulated with a certificate of need program in place. At that time there were never more than 100 home health agencies in the state, and all were Medicare-certified. The state legislature deregulated home care in 1981, and under pressure from the private sector, Congress approved Medicare reimbursement for the for-profit sector in 1982. By 1983, Texas had over 700 licensed agencies, which at one point rose to 1,000. Five hundred fifty were Medicare— certified and that number peaked at 600 in 1983—84. The DRG system affected this by encouraging more people and institutions to move into the home care business because of more patient referrals. All the hospitals did. So did, for example, Upjohn, the Beverly Foundation, Kelly Girls, and nurses. The nurses ran agencies equivalent to "Mom and Pop" businesses and had to fight the big chains for their market share. But, the severe depression of the Texas economy due, to falling oil prices, and increases in retroactive denials (e.g., the fiscal intermediary gave verbal approval for services and then would deny payment for those services in writing after they were delivered) have had their effects on this industry. By the fall of 1985, 93 agencies started to close to the point where there were 800 remaining in the state--400 of which were Medicare-certified. The state is continuing to lose agencies. Most of the people who did drop out of the home health business in the very rough years of 1983-1986 were too dependent on Medicare and Medicaid reimbursements. An understanding of clinical skills and business skills are not enough to succeed in home care in Texas now. One also needs a "deep pocket." Unless an agency is part of a large chain with 5-7 years of a red line budget, don't try it. Hospitals are the only ones in the state who have such budgets. It is Mr. Water's impression that the home health care nurses are very frustrated. They have large caseloads, work with unskilled help, and spend 60% of their time on paperwork, so they haven't escaped the institutional parts of the job that motivated them to leave the hospitals. Texas also has a severe nursing shortage now, even in home care, so that while they are overworked, their salaries have increased. Major issues revolve around finding a way to stabilize home health. The Association is looking for ways to help people stay in business. Thus, they are offering low—cost health insurance for contract employees and group medical supply purchases. 11. Terri Avers. Assistant Director, Visiting Nurse Association (VNA) of Northern VirginiaI Arlington. While this agency had increased its number of visits prior to DRGs, the agency has grown dramatically since their implementation. Services have also gotten more technical and more intensive. For example, week-end nurses used to be on call on Saturdays from 94 9 a.m. to 12 p.m. Presently, seven nurses are working each week-end, with a back—up nurse on call, since increasing numbers of patients require daily visits. At the same time HCFA is increasing its denials and will pay only for the care of someone who is getting better or worse. But there is a gap in services for people who have improved enough to be discharged from the agency but who are not yet independent. Fortunately for the people in that area of the state, the health department has a model chronic disease program that includes custodial care. The staff-related issues that need to be addressed include the following: (a) AIDS. Staff nurses are concerned about caring for AIDS patients although none have refused to deliver services. Also, the patients with AIDS are living longer if they are on AZT, so they are staying in the community, and services need to be available there. (b) Experience. The agency is hiring only nurses with recent medical—surgical experience or experiences in similar home care agencies because they need to be "up to the minute" in their technical skills. (c) Recruitment. There has been little response to their ads in the past few weeks. The schools of nursing in Virginia, it seems, have had 25-50% drops in enrollments in the past three years. To stay afloat, the agency is constantly developing new policies so they can expand the range of their services safely. They are competing with the for-profit agencies by increasing their marketing efforts, and by having liaison nurses in the local hospitals so they get the available referrals. 95 12. Cheryl Screiber. Executive Director. West Virginia Council of Home Health Agencies. This state's home care industry was also growing prior to the DRGs. One-third of the home health agencies are based in health departments and 85% of the caseloads are Medicare patients. The state has an increasingly elderly population, expected to reach one-quarter of its total population. The state is also in a financial bind, so the Medicaid program is being cut back. With Medicare increasing its denials and Medicaid being reduced, neither the agencies nor the patients will be getting what they need. In summary, the SREB region's health care industry was expanding prior to 1983. The DRGs for hospital care further expanded the industry, but also increased competition, and the denial rates from Medicare. Currently, there is a good deal of confusion in the industry about who is eligible for the Medicare home care benefit even though the elderly patients seen since the adoption of the DRGs are sicker, require more visits, and more highly skilled care. Agencies are responding to this by, among other things, hiring more business people, diversifying their services and their reimbursement sources, and developing in-service education programs for staff on skills updates, and regulations governing reimbursement. Some states must now deal with the implications of the nursing shortage for home care and, lastly, concerns were raised about indigent care (who will pay for it) and about the quality of home care. Implications for Nursing Education in the SREB Region Demographic analysis indicates that the population in the SREB states will grow at twice the national rate until the turn of the century, at which time the elderly will constitute a larger proportion of the total population 96 (Southern Regional Education Board, 1986). Thus, the care of the elderly and costs of that care will continue to be a major health care problem for decades. In light of this, and given the points made in this paper about acuity and intensity levels of care, policy issues, management problems, competition, cost containment (the list can go on), how should nursing education be affected? It would be a mistake to conclude that all that is needed is to set standards for teaching gerontology content, health policy analysis, business and management skills, intensified clinical skills, insurance issues, the Medicare cost report, quality assurance, etc., in the undergraduate curriculum. While I agree that such skills are certainly important and that we need to educate a certain percentage of nurses with these skills, there are more fundamental issues that need to be addressed at the undergraduate level but which are not clearly met by simply introducing courses in other fields into the nursing curriculum. In this time of cost containment in both the public and private sectors, health care providers will have to make new kinds of decisions regarding treatment, both in and out of the hospital. The specific problem will be, what constitutes proper treatment? Since the decision to discharge or retain a patient in a hospital or home health agency is not based solely on what is. medically possible or even on what is economically possible, we need to educate health care providers to be able to make such decisions. The problem, however, is identifying what these decisions should be based on. Factors other than clinical or economic shape patient care decisions. For example, these decisions reflect our community values, especially with regard to justice. As the establishment of the DRG program suggests, we as a society regard the health care of our citizens as not a matter of charity but rather as a matter of justice and duty. 97 The curriculum must enable the nurse to make responsible decisions concerning what constitutes adequate treatment. The nurse, for example, must not be in the position of passively reacting to such decisions, made by the hospital comptroller or federal agents, because such decisions are, despite the current situation, still health care decisions. The task for educators is thus to respond by identifying the factors that inform such decisions and teaching our nurses accordingly. This will involve carefully examining the criteria of adequate care, the goals of treatment, perhaps the goals of particular kinds of treatment (e.g., the goals of hospital treatment, the goals of home-based treatment). At what point should the professional say, "We have done all that we can do." Home health agencies are in a complex situation: If an agency does not deliver needed services, it is subject to charges of malpractice; if an agency delivers so-called inappropriate services, it will not be paid. Given this situation, it would certainly be in the interest of the home health agency to have nurses who not only can manage care and but who can also make and justify decisions about what care is needed. These decisions will also raise ethical issues. What are our obligations (i.e., the obligations of the health professional, the hospital, the local community, the federal government--as indicated in the establishment of DRGs--the family, etc.) in caring for this individual? What control should the patient have in the location, kind, or amount of treatment? It is not clear whether simply taking set courses in other fields, such as philosophy, business, public policy, or law, would provide such training in decision—making. Multi-disciplinary research projects will have to be supported to prepare for curricular needs in this area. 98 PROPOSED AGENDA Meeting on DRG Impact on Undergraduate Nursing Education in the South Atlanta, Georgia October 5, 1987 1:00 pm Welcome, introductions, and plan for meeting 1:30 1:40 1:50 2:20 3:15 to 3:15 3:15 3:25 3:55 4:35 4:40 5:00 Audrey Spector Cora Balmat Mary S. Hill Impact of DRGs on clinical nursing practice in large teaching hospitals Barbara A. Donaho Highlights, sample survey of region’s hospitals * Shirley J. Carey Roundtable discussions (3 tables, 5 persons each) Each table identify the 5 most important effects of DRGs on clinical nursing practice in hospitals Total panel--reports from 3 tables, agree on most important impacts of DRGs on clinical nursing in hospitals Refreshment break Impact of DRGs on nursing practice in community settings Judy Baigis-Smith Roundtable discussions Each table identify the 5 most important effects of DRGs on clinical nursing practice in community settings Total pane1--reports from 3 groups, agree on most important impacts of DRGs on clinical nursing in community settings Discuss plan of events for following morning Adjourn No host social hour 99 October 6, 1987 8:45 am Implications of DRGs for undergraduate nursing curricula Frances Henderson 8:55 Highlights, regional survey of nursing programs * Eula Aiken 9:05 Roundtables Each table identify 5 most important implications for undergraduate nursing education 9:35 Total panel--reports from Roundtables, agree on most important effects of DRGs on undergraduate nursing education 10:05 Refreshment break 10:20 Total panel Develop conclusions and recommendations 12 noon Adjourn * Report will be distributed at meeting. NOTES Undergraduate nursing education, for purposes of this discussion includes all types that lead to RN licensure: Diploma, associate degree, bacca- laureate, and the master’s program at the University of Tennessee, Knoxville. Community settings include VNAs, community health centers, home health care (public or private), state health departments. Not nursing homes, unless used for student experiences, and not hospital out-patient departments. The purposes of the Panel of Experts meeting on October 5-6 are to: arrive at conclusions as to the impact of prospective payment systems on clinical nursing in hospital and community settings, identify implications for undergraduate nursing curricula; formulate recommendations for clini- cal and didactic nursing courses for undergraduate nursing education, for example, regarding geriatrics, community health, home care; arrive at con- clusions and recommendations which may be short and/or long range; region-specific, local, state, or national. 100 ROSTER Panel of Experts Impact of the Prospective Payment System (DRGs) in the Reimbursement of Hospitals, on Clinical Nursing Care in Hospitals and in Community Settings. October 5-6, 1987 Atlanta, Georgia Cora S. Balmat Director, Division of Nursing Alcorn State University Natchez, MS 39120 Betty L. Battenfield Chair, Department of Nursing University of Arkansas 217 Ozark Hall Fayetteville, AR 72701 Eileen Bland Director, Health Department, Home Care 241 East Walnut St. Jesup, GA 31545 Cora E. Braynon Senior Nursing Executive Director Broward County Public Health Unit 2421 Southwest Sixth Avenue Fort Lauderdale, FL 33315 Billye J. Brown Dean, School of Nursing The University of Texas at Austin 1700 Red River Austin, TX 78701 *Shirley J. Carey Associate Professor Nell Hodgson Woodruff School of Nursing Emory University Atlanta, GA 30322 101 *Barbara A. Donahoo Vice President, Nursing and Patient Services Shands Hospital at the University of Florida 1500 Archer Road Gainesville, FL 32610 *Frances C. Henderson Chairman, Department of Baccalaureate Nursing Alcorn State University Natchez, MS 39120 Cennette F. Jackson Coordinator, Baccalaureate Program School of Nursing Georgia State University Atlanta, GA 30303-3083 Diana Mullins Director of Nursing Service Clayton General Hospital 11 S. W. Upper Riverdale Road Riverdale, GA 30274 Julia L. Perkins Director, Nursing Education Kennesaw College Marietta, GA 30061 Elaine C. Phillips Associate Professor in Nursing and Epidemiology University of Virginia McLeod Hall Charlottesville, VA 22903 *Judith Baigis Smith Kathy Zeigler, Director Director, Long Term Care and Visiting Nurse Association Home Health Promotion 100 Edgewood Avenue, N.E. The Johns Hopkins University Atlanta, GA 30303 School of Nursing 600 North Wolfe Street Baltimore, MD 21202 Mary S. Hill Chief, Nursing Education Branch Division of Nursing, BHPrs, HRSA 5600 Fishers Lane Rockville, MD 20857 Audrey F. Spector **Eula Aiken Nursing Programs Director Director Nursing Computer Project Southern Regional Education Board 592 Tenth Street, N.W. Atlanta, GA 30318—5790 *These members of the Panel of Experts also authored a paper which was shared with the panel and is included in this publication. **Also authored a paper. 102 Ill-I‘ll I [Lill “.6. BERKELEY UBBANES CUDHHQELHE Us DEéAfiTMEN’T Q‘E HEALTH 8 HUMAN SERVICES :qu,”; Hgguh 'Sewii'qé