Nurse Turnover In Home Health Care

Nurse Turnover In Home Health Care

MSA 699 Administrative Research and Report Methods

Submitted by:

Michelle Jones

Project Instructor:

Ronnie D. Wilson

Table of Contents

Page Number

Executive Summary ………………………………………………..i

List of Tables ………………………………………………………ii

List of Figures……………………………………………………ii

Chapter IProblem Definition …………………………………2

Chapter IILiterature Review ………………………………….8

Chapter IIIResearch Methodology …………………………….21

Chapter IVData Analysis ………………………………………Future

Chapter VSummary, Conclusions, and Recommendations …..Future

Terminology and Definitions……………………………………Page 24

References …………………………………………………………Pages 25-28

Appendix APermission to Conduct Study

Appendix BConsent Form (Anonymous Survey, Informal

Interview or Formal Interview)

Appendix CSurvey Questions

Executive Summary

This proposal seeks to undertake a study on the turnover of nurses in home health care and its effects of the same on patient care. Home health care has been established as an accepted mode of patient care given the rapidly changing healthcare environment. More and more of the aging population are electing to live independent, non-institutionalized lives, and are receiving home care services as their physical capabilities diminish. Both older and younger adults who are disabled or recuperating from acute illness are choosing home health care whenever possible. Chronically ill infants and children are receiving refined medical treatment in their loving and secure home environments. Adults and children diagnosed with terminal illness also are being cared for at home, receiving compassion and maintaining dignity at the end of life. As hospital stays decrease, increasing numbers of patients need highly skilled services when they return home. Other patients are able to stay at home to begin with, receiving safe and effective care in the comfort of their own homes. Generally, home care is appropriate whenever a person prefers to stay at home but needs ongoing care that cannot easily or effectively be provided solely by family and friends. This in turn has caused the home health care sector to attract an increased number of alternate service providers as well as a subsequent increase in fraud within the division. It would therefore be important to undertake a study aimed at understanding the vices that threaten this very important sector and come up with recommendations that would be critical in ensuring the industry remains vital. The approach that would be adopted for this study will however not be conclusive on matters of home health care and future research should attempt to address areas that will have been left out in this study.

Chapter I

Problem Definition

Administrative Problem

Background

Home health care is about delivering medically related services to patients in a home setting rather than in a medical facility. Generally, home health care is appropriate whenever a person prefers to stay at home but needs ongoing care that cannot easily or effectively be provided solely by family and friends. This can sometimes be confused with in home care.

In home care does not require a doctor’s prescription and does not include skilled nursing services. Home health care nurses can administer medication, whereas homecare aides can only provide reminders to take medication. Both home health care and homecare provide companionship and assistance with the activities of daily living (ADLs). Some people engage both services at the same time, as they balance each other well, depending on the services required. Home health care focuses on skilled care, while home care aids with or takes over light household chores. Generally, home health care is appropriate whenever a person prefers to stay at home but needs ongoing care that cannot easily or effectively be provided solely by family and friends. More and more older people, electing to live independent, non-institutionalized lives, are receiving home care services as their physical capabilities diminish. Younger adults who are disabled or recuperating from acute illness are choosing home health care whenever possible. Chronically ill infants and children are receiving refined medical treatment in their loving and secure home environments. Adults and children diagnosed with terminal illness also are being cared for at home, receiving compassion and maintaining dignity at the end of life. As hospital stays decrease, increasing numbers of patients need highly skilled services when they return home. Other patients are able to stay at home to begin with, receiving safe and effective care in the comfort of their own homes.

Home health care includes part-time or intermittent HYPERLINK “http://www.medicare.gov/homehealthcompare/Resources/Glossary.aspx?toolAudiance=HHC&Language=English&TermID=0021” o “Click to see the glossary item skilled nursing care.” skilled nursing care, and other skilled care services like HYPERLINK “http://www.medicare.gov/homehealthcompare/Resources/Glossary.aspx?toolAudiance=HHC&Language=English&TermID=0017” o “Click to see the glossary item physical therapy.” physical therapy, HYPERLINK “http://www.medicare.gov/homehealthcompare/Resources/Glossary.aspx?toolAudiance=HHC&Language=English&TermID=0016” o “Click to see the glossary item occupational therapy.” occupational therapy, and HYPERLINK “http://www.medicare.gov/homehealthcompare/Resources/Glossary.aspx?toolAudiance=HHC&Language=English&TermID=0023” o “Click to see the glossary item Speech Therapy.” speech therapy. Services may also include HYPERLINK “http://www.medicare.gov/homehealthcompare/Resources/Glossary.aspx?toolAudiance=HHC&Language=English&TermID=0013” o “Click to see the glossary item medical social services.” medical social services or assistance from a HYPERLINK “http://www.medicare.gov/homehealthcompare/Resources/Glossary.aspx?toolAudiance=HHC&Language=English&TermID=0010” o “Click to see the glossary item home health aide.” home health aide.

Examples of skilled home health services include:

Wound care for pressure sores or a surgical wound

Physical and occupational therapy

Speech Therapy

Patient and caregiver education

Intravenous or nutrition therapy

Injections

Monitoring serious illness and unstable health status

Examples of home health aide services include:

Help with basic daily activities like getting in and out of bed, dressing, bathing, eating, and using the bathroom

Help with light housekeeping, laundry, shopping, and cooking for the patient

Home health care involves the qualification of skilled nursing care as well as certain other healthcare services at the comfort of a patient’s home normally for the treatment of an illness or an injury. Before a patient has access to home health care, it is very important that the approval of the patient’s physician is ascertained to the effect that the patient actually needs medical care at home. This would ensure that sufficient arrangement is made for the provision of such care at home. The nature of care that may be rendered at home may include skilled nursing care, speech language pathology services, and physical therapy (Senior Health, 2010).

A patient who receives home health care should be home bound, meaning there should be sufficient grounds for the patient not to leave home, or if leaving home is a necessity it is limited to one to two hours for doctor’s appointments. It is also important that home health care services are only rendered by licensed agencies that are approved by the relevant regulatory bodies. The trend of home health care is steadily gaining popularity partly because of high in-patient service costs, and also due to the increased burden on facilities within most healthcare institutions. Elderly patients and infants are also more conveniently attended to at home in their familiar environment (Senior Health, 2010).

Home health is forecasted to grow by over 42% in the next five years, as key demographic drivers remain in place throughout this decade. At the same time, the number of certified home health agencies operating in the U.S. has decreased from over 14,000 to less than 8,000 since 1996 thus significantly decreasing local market competition. This presents enormous opportunity to forge new client relationships where entrenched competition was previously present.

Shoppers Home Health Care is a leading Canadian organization that specializes in the provision of a complete selection of specialty home health care products and services which are designed to meet the specific needs of patients for health recovery and maintenance. This company that has been in existence for close to 40 years was established on a foundation of professional expertise and personal services. The company has since grown to have close to 50 locations within Canada and beyond (Shoppers HomeHealthCare, 2010). This organization specializes in a wide range of home health care services including custom modification of seating and mobility equipment, wheelchair vans, and other aids to improving daily living. Other specialty services include free consultancy for on-going repairs and services of certified technicians. The organization also specializes in setting up of temporary home care environments without costly renovations, offers access to clean, safe and reliable equipment for home use, rental services of home health care equipment, and other home health care solutions designed to meet the specific needs of each patient (Shoppers HomeHealthCare, 2010).

The success of Shoppers Home Health Care can be attributed to the strong relationship with its clients and the high and reliable quality products and services. The organization prides in the frequent positive feedbacks from their clients who acknowledge newfound freedom from home based health care offered by Shoppers Home Health Care. The organization strives to ensure that their services, sales, and equipment meet the latest standards associated with high quality as well as client expectations (Shoppers HomeHealthCare, 2010).

Research Problem

What are the effects of home health care on the patients that receive such services? What are the key challenges that are faced by home health care service providers in the United States? How best can the home health care sector be protected from problems associated with fraud and abuse? What role can the home health care sector stakeholders play in preventing health care fraud and abuse?

Home health care is based on nursing and rehabilitation services to prevent the admission or readmission of a patient to a hospital. Many seniors and terminally ill patients prefer to stay in their own homes if possible while receiving treatments which may have been normally provided through a lengthy stay in a hospital and Home health care can help to facilitate this. Home health can provide nursing care, occupational therapy, physical therapy, speech therapy and medical social work services needed for an acute health need. While patients are receiving skilled care, the organization can also provide a home health aide to assist with personal care such as help with dressing, meals and bathing. These forms of services are very personal and require positive attitudes, the ability and willingness to be helpful and trustworthy. Patients and the quality of care they receive must always be the number one issue on the clinician’s agenda. For the patient the perpetual turnover causes them to be unnerved. There is no consistency with care due each clinician performs duties in their own personal style and patients become use to having the same person, for six months or more and suddenly there is a disruption and patients will sometimes relapse or cancel care altogether.

Home health care is steadily gaining popularity in the United States. This is mainly attributed to the increasing number of the elderly most of whom are home bound. Subsequently, the sector has attracted numerous players who step in to meet the increasing needs of patients requiring home health care. The influx of home health care service providers in the United States has led to a rise in cases of fraud and abuse of the system. Home health care fraud entails deliberate misrepresentation, deception, and intentional cheating for purposes of getting higher reimbursement. This is a practice that is highly inconsistent and goes against acceptable business and medical practices in the United States (BlueCross BlueShield of North Carolina, 2010).

The most common types of home health care fraud and abuse by service providers include billing for services that are not rendered, submitting claims for services more than once, misrepresenting the services that were rendered, charging for a more expensive service contrary to the actual service rendered, and billing for a service that is covered when the actual service rendered is not actually covered. This type of fraud has made deceitful clinicians to continually turnover in home health care. Though home health care is designed to ensure that homebound patients are attended to within their familiar and friendly environments as a way of facilitating recovery, fraud and abuse of the practice has grossly put to question and eroded the credibility of service providers (BlueCross BlueShield of North Carolina, 2010).

Clinicians in home health care have been known to significantly improve the recovery rates among the patients receiving such services. This is particularly so given the familiarity and friendliness of the home environment. It is also an important approach to reducing the strain that exists on medical facilities, and a means of saving the patients from incurring huge in-patient medical bills. Home health care has thus been a great business and a lucrative sector within the United States healthcare field. The practice is however facing real challenges arising from fraud and abuse by certain practitioners. It is therefore important that all stakeholders in this field play a role in preventing this problem. This would help in ensuring that only credible players like Shoppers Home Health care render this necessary service. The key challenge has thus been on improving the image of this sector as well as reclaiming the lost public confidence in the service providers. Home health care plays an important role on patient recovery and should thus be safeguarded from any form of abuse.

Scope

The influx of unscrupulous clinicians in the home health care sectors is a matter of great concern to both the government and the stakeholders of this sector. Such concern is very crucial to key players like the Shopper Home health Care since a negative practice within the sectors would translate to major reputation loss to the organization. The main research question is: “What is the main cause for the continued turnover by clinicians in home health care over in-patient services?” The research sub-questions include:

What are the effects of home health care on the patients that receive such services?

What are the key challenges that are faced by home health care service providers in the United States?

How best can the home health care sector be protected from problems associated with fraud and abuse?

What role can the home health care sector stakeholders play in preventing health care fraud and abuse?

Chapter IIReview of the Related Literature Introduction of the Literature

Literature review in this research paper has been used to give an insight of the topic of study and this covers a large section of the research methodology. The literatures reviewed in this study include books, journals, publication from university and articles. The purpose of using literature review is to get the views of other different scholars who had visited this topic before and this has made the research to expand the search perspective and therefore operate in a narrow scope (Armitage et al. 2009). Focusing on a specific subject has made it easy to obtain data and also to utilize the relevant literatures. This has provided a good base for the study as the study has been well highlighted. Case studies are good for the researcher as they provide a direction for the study (Hartley 1994). Case studies have capabilities that allow for the manipulation of the data collection process to the research questions. In other words they provide a working ground for the researchers to evaluate their study and be able to get reliable results.Much emphasis has been laid on the problem of fraud and abuse that has grossly dented the reputation of the sector players and has led the government to lose billions of dollars in malpractice claims.

Fraud in Home Health Care

Home health care has for a long time played and still plays a very important role in the United States. This is particularly so given the ever increasing number of the elderly who are the majority of home bound patients who mostly require home health care. The increase in Medicare and Medicaid population has significantly led to an increase in the number of home health care providers and an equivalent increase in the cases of fraud and abuse that continue to dent the image of this sector. The key malpractices that dominate this sector mainly involve improper provider claims and billing (Buto, 1997).

Incorrect billing claims may result not only from deliberate actions but also errors of confusion and misinformation on proper billing procedures. This has meant that even credible organizations have also been caught in this mix. The billing fraud has been facilitated by the increased number of home bound patients who are mostly unable to monitor their own bills, and at the same time not have family members to act on their behalf. This has made such patients easy prey to fraudulent clinicians and organizations (Buto, 1997).

This problem is bound to persist for a longer time given the rate at which the elderly population is increasing, and the changing face of the health care environment. Such phenomena have presented a good opportunity for the individuals who are keen on defrauding Medicare to target very ill patients who are incapable of monitoring their own bills for fraudulent billing. The concentration of a large number of the elderly within certain geographical localities has also created a zone that is ripe for exploitation by fraudsters (Buto, 1997).

Durable Medical Equipment

Durable medical equipment (DME) fraud has also gained prominence as part of the home health care fraud. This would include equipment that can be repeatedly used to serve a medical purpose and would be appropriate in a patient’s home setting. This type of equipment only qualifies for claims payment if and only if they are ordered for by a physician through a certificate of medical necessity. The necessity standards mean that the equipment must have been ordered, provided, is reasonable and necessary as well as meets the criteria established by the medical review policies (Nolan & Auerbach, P.A, 2009).

Durable medical equipment are subjects of fraud in circumstances in which the suppliers seek for reimbursement for items provided though not ordered for by the treating physician or other authorized person. Fraud also occurs when the supplier bills for substantially more items that are necessary for the needs of each individual patient. At the same time, fraud is committed when a supplier bills for items that do not meet the definition and requirements ordered by the treating physician. Fraud under this class also involves attempts by suppliers to provide free gifts to physicians to sign certificates of medical necessity in their favor, and also when supplies that are no longer necessary are dumped in a beneficiary’s home (Nolan & Auerbach, P.A, 2009).

Healthcare is faced with disturbing staff instability (Woltmann et. al, 2008; Hayes et al, 2006). In a literature review, Hayes and colleagues concluded that high nurse turnover is capable of impacting negatively on the ability of an organization to provide quality healthcare that meets patients’ needs (Hayes et al, 2006). Literature demonstrates that home health care is experiencing difficulties in recruiting and retaining nurses for home care (Flynn, 2008). In 2001, the United States General Accounting Office estimated that the national attrition rate among home health care registered nurses (RNs) was 21%, while it put the vacancy rate for the same at an approximation of 18% (Flynn, 2008). This literature review will therefore primarily focus on home health care and nurse turnover. A clear understanding of nurse turnover will make it possible to study the effect of that turnover on patient outcomes; specifically the possibilities of necessitating remedial care in home health care nursing.

Meaning and Role of Home Health Care

Broadly defined, home health care refers to those services substituting services that both long-term care and short-term care institutions provide to the elderly, chronically ill, or people with disabilities; as well as preventive services aimed at delaying admission into a hospital or an institution specializing in long-term care (Flood, 2002). In delivering these services, home health care agencies provide various services. For instance, they are involved in the provision of physical therapy, home assistance, skilled nursing care, and occupational therapy (Bruce et al, 2002). Cluff & Binstock (2001) notes that “home health care promises independence and social integration, enabling individuals to remain in a familiar and comfortable environment in which they can maximize control over their lives” (n. p.), as opposed to nursing homes which are restrictive and, to some, represent abandonment. The authors proceed to observe that the concept of “home” in home care symbolizes unity, love and care, and therefore has a restorative effect (Cluff & Binstock, 2001).

Although there has been controversy concerning the role of home health care, studies have demonstrated that home health care services play an essential role in the healthcare system, explaining why the need for home health care is on the rise (e.g. Hughes et al., 2000; Flynn, 2008). First, home health care visits for elderly people are designed to either delay or prevent functional impairment and as such prevent nursing home admissions or re-admissions (Stuck et al, 2002; Bruce et al, 2002). In this case, home health care services that are aimed at preventing decline of functional status in the elderly include primary prevention, secondary prevention, and tertiary prevention. Primary prevention may involve administering immunizations and helping the elderly do exercises while the secondary prevention may involve detecting problems that were not treated or detected earlier. Additionally, tertiary prevention may include, for example, improving the use of medication by the elderly (Stuck et al, 2002).

In a study designed to assess the effect of home health care visits in preventing or delaying decline in the functional status of elderly people, Stuck and colleagues found that preventive home health care visitations do effectively delay or prevent impairment of functional status in the elderly if interventions draw from multidimensional geriatric assessment. Additionally, the authors reported that such visits need multiple follow-ups. They further found that the programs are most effective if the target people are those relatively young and less likely to die (Stuck et al, 2002). Another study by Hughes and colleagues found that home-based primary care was effective when team-managed. Specifically, the authors found that team-managed home-based primary care improved functional status, patient satisfaction, caregiver’s satisfaction with the care; reduced burden for caregivers, and reduced the possibility of hospital admission (Hughes et al, 2000).

Home health care is also meant for people with disabilities (including older people), a number that is expected to rise in the US following the shifts in demographic, social and organizational trends (Katz, Kabeto & Langa, 2000). Specifically, by 2050, the US population is of elderly will be substantial, and as such disabilities associated with aging and chronic diseases are expected to be on the rise. Second, nursing home use is projected to reduce and this will bring about increased number of severely disabled people in the community. Third, the pattern of living arrangements is changing and its effect will be felt in the home health care industry due to the increase of elderly in the community who will be living alone; the consequence of which will be reduction in informal care (Katz, Kabeto & Langa, 2000).

Nurse Turnover

Nursing turnover refers to the process in which nursing staff leave or transfer in the context of the hospital environment, either voluntarily or involuntarily; and internally or externally (Hayes et al, 2006). At times, nursing turnover can be beneficial to an organization, according to Jones & Gates (2007). For instance, as a consequence of nursing turnover, there is a reduction in cost in that salaries for the nurses who leave or transfer to other departments are retained by an organization. Additionally, there are benefit costs and vacation pay for an organization’s new employee as a result of turnover. Moreover, productivity increases when employees are provided with duties in which they can realize their full potential and as such register the greatest performance. The organization saves on the dues that it does not pay to the nurses who leave the organization. Furthermore, turnover is responsible for gains resulting from integration of knowledge and ideas following replacements, decreased portrayal of withdrawal behavior, and policy changes simulations (Jones & Gates, 2006).

On the other hand, turnover rates reaching and exceeding 50% produce negative effects to an organization. In the context of home health care, this effect is greatly felt (Flynn, 2008). This is why the present study seeks to establish whether turnover in home health care results in remedial care. In this light, retention becomes an option for organizations. Retention benefits are realized through reductions in advertisement and recruiting, reduced vacancy costs, reduced orientation and training costs, maintained and increased productivity, and reduced termination costs (Jones & Gates, 2007). Other benefits of retention are accrued through increased patient care due to decreased patient errors, improved work environment, increased job satisfaction, preserved organizational knowledge, and easier recruitment of nurses (Jones & Gates, 2007).

Theoretical Explanation of Nurse Turnover

Researchers have made attempts to establish the relationship existing among turnover determinants. Generally, job satisfaction, commitment to the job, and availability of better jobs are responsible for turnover (Holtom & O’Neill, 2004). Satisfaction with the job and commitment to that job and the organization are shaped by factors related to the demographics, organization, and the environment, including job opportunities within the environment. There are two kinds of job satisfaction that include organizational and professional. Organizational job satisfaction has to do with group cohesion, control over decisions and job stress while professional job satisfaction involves how a nurse perceives quality of care, the time they have for their job, and the joy they derive from doing their job (Hayes et al, 2006).

Another model advanced to explain turnover is the progression model that takes account of the basic units of the profession. According to this model, a nurse first thinks about leaving a ward, then a hospital, and finally the profession. In a way, the primary determinant of nurse turnover according to the progression model is the withdrawal behavior in the lower levels of the profession such as a ward. Generally, in all the models that have been advanced to explain nurse turnover, a nurse’s intention to leave is the primary predictor (Hayes et al, 2006).

Factors Responsible for Nurse Turnover

Factors that have been identified as being the determinants of nurse turnover are job satisfaction, and organizational, economic, and individual factors.

Job satisfaction

Job satisfaction in nursing has been strongly linked with nurse turnover (e.g. Alam & Mohammad, 2010; Murrells, Robinson, & Griffiths, 2008; Molinari & Monserud, 2008; Flynn, 2008). It has been found that job dissatisfaction is among the leading causes of turnover among home care nurses (Flynn, 2008). For instance, Flynn (2008) carried out a study in which 30% of home health care nurses reported that they were dissatisfied with their job; and that 26% were planning to quit their jobs within the period of one year. Instruments that measure job satisfaction in nursing basically contain eight factors that have been identified as determining job satisfaction. These factors include scheduling, balance between work and family, extrinsic rewards, professional opportunities, interactions, co-workers, praise or recognition, and control or responsibility (Hayes et al, 2006; Alam & Mohammad, 2010). Low job satisfaction is responsible for nurse turnover. Nurses value job satisfaction more than outside opportunities (Shields & Ward, 2001). An improved quality of work at an organization improves retention of nurses (Stones et al, 2007).

Organizational Factors

Organizational factors have to do with the workload, empowerment, management style, nurse autonomy, work schedules and opportunities for promotions. First, empowerment and autonomy determine whether nurses will leave or stay. There are two types of empowerment: structural and psychological. Structural empowerment has to do with whether the nurse perceives empowering conditions as present or absent in their work place; while psychological empowerment concerns itself with how the nurse reacts or interprets such conditions (Laschinger et al, 2004). Structural empowerment, specifically, involves support, resources, opportunity, information, formal power, and informal power; while psychological empowerment involves competence, meaningful work, autonomy, and impact. Structural empowerment directly affects psychological empowerment (Laschinger et al, 2004). Studies have found that psychological empowerment strongly predicts job satisfaction which is responsible for retention (Hayes et al, 2006).

Second, workload, stress, and burnout have been identified as determinants of nurse turnover (e.g. Vahey et al, 2004). Hayes and colleagues observed that a consistent increase in workload results into increased tension at work which is responsible for reduction in job satisfaction. In home care, work load takes the form of the number of patients in the caseloads of the nurse, scheduled patients in total, and the actual visits that the nurse manages to conduct (Flynn, 2008). Job satisfaction as already noted causes nurse turnover. It has been observed when a nurse gets an additional patient, which represents an increase of 23% for the possibility of burnout, as well as a 15% increase in the probability of job dissatisfaction (Hayes et al,