Professional Nursing and HCBS Consumer access through nurse delegation Rosalie A. Kane, School of Public Health University of Minnesota Regional State Training on Olmstead Implementation, 2001 Elderly people and Olmstead * Seniors = largest group in nursing homes * Seniors = least likely to benefit from Olmstead • conscious planning needed • building senior constituency • inspecting existing policies Why the senior disadvantage? * Age inequities in state/waiver programs • PAS for younger, agency for 65+ * sheer numbers & $ implications of change * ageism & protective instincts • among providers, family, & seniors • less disabled seniors served in HCBS * no constituency for reform * health needs: real & perceived * mixed agendas of seniors Assisted living and HCBS * not all AL should count as HCBS • counting in waiver not enough • privacy & consumer control threshold • some AL as institutional as NH • some AL like private apartment * AL rules need inspection for: • admission & retention requirements • move-out rules • environment rules Strategies on behalf of seniors * build constituencies * education & dialogue • providers, regulators, ombudsmen, citizen groups * review statutes, regs, & practices * make managed (negotiated) risk contracting operational * nurse delegation issues Managed risk contracting * consumer knowingly accepts risk • after information about risks & consequences * provider makes plan to mitigate risks * consumer cannot waive basic quality * all concerned parties sign written statement Issues in managed risk * what risks count • health, social, psychological * are risks of NH considered * how often are risks evaluated * who explains risks * proxy roles in risk assumption Health care needs * routine help with medications • oral, topical, suppository, injection, inhalator * routine nursing procedures * monitoring status when consumer cannot * when licensed personnel needed $ é * self-care abilities may decline with age • motor, visual, & memory problems * BUT typically seniors have ADL/IADL help who could be delegated to do nursing Nurse delegation definitions . . . transfer of authority from a licensed health care provider to an individual not licensed to perform the delegated tasks within a specified situation (DHHS) transferring to a competent individual the authority to perform a selected task in a selected situation, with the nurse retaining authority for delegation (MN) the RN may delegate selected nursing tasks in the implementation of the nursing regimen to LPNs and ancillary nursing personnel. Ancillary personnel include but are not limited to: aides, attendants, and technicians [NJ] Terminology * Delegation • individualized delegation * Assignment • delegates taught category of task & approved for that task (e.g. oral meds) * Exemption • certain circumstances declared outside nurse practice • sometimes family, domestic service, attendants Delegation facts * Nurse practice acts build in delegation • statutory change may not be needed * Clarifications may be needed * Provider license rules may be inconsistent with delegation * Types of delegation policies vary: need to know state State policies * General delegation authority * List of what may be delegated * List of what may not be delegated * List of who may delegate & to whom by occupation * Specification of permissible settings for delegation More state policy possibilities * Pre-training for nurse doing delegation * Pre-training for delegated person * Informed consent of consumer * Intervals for monitoring * Limited liability for nurse who delegates * if she teaches right, she is immune from bad performance of delegate Nurse concerns about delegation * safety and quality * liability • legal • board of nursing license * control over own profession Evaluation of delegation * Washington evaluation • almost no negative effects (13 instances, none serious) • in settings opting not to delegate, more nursing practice errors & more serious • nurses in loop & more able to be helpful • improved access for consumers • task force recommended loosening policies * No bad outcomes in Oregon--doing it since early 1980's Can physicians delegate? * Historically MD's instruct family & private-duty helpers * Possible end-run around nurses * May have negative impact in long-run • ability to be systematic with MD's harder • negative reactions among nurses • nurses should be in loop sometimes Strategies to make delegation work * statute or reg ( changed practice * training & procedures useful * payment for nurse delegation an issue • supervising delegation Medicare ( skilled service • state hiring nurse consultants Specific stumbling blocks * PRN meds • establish parameters * injections Overview * nurse practice issues still halts reform * multifaceted opportunistic approach * nurse practice statutes & setting licenses • regulatory clarification • training & communication * payment sources * as needed, consider full range of delegation, assignment, and exemption * less prescriptive delegation rules best • nurse retains discretion Dealing with political obstacles * identify problem • legislature? nursing board? providers? advocates? * get groups talking * get started with time-limited plan * build in evaluation * get quality surveyors on board Page 181