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The organization where I gained practicum experience is called VNS CHOICE. It is a long-term care program that is managed by MEDICAID. The patients should be sixty five years or older; they have MEDICAID for insurance and have medical conditions or co morbidity that require care management by a registered nurse. Most of the patients have chronic medical conditions and decreased functional conditions that would qualify them for long term care in a nursing home. These patients can however remain safely in the community thus saving costs of having them put in a nursing home. Most of the patients are dually eligible which means that they also have insurance by Medicare.
VNS CHOICE is under the direct oversight of a Chief Executive Officer who is also President of the Visiting Nurse Service of New York. VNC CHOICE contributes to an estimated forty one per cent of the total revenue for VNSNY. There is an executive management group that is responsible for various functional domains of the organization’s health plan. The domains are administrative operations, clinical operations, medical leadership and finance. The Chief Medical Officer oversees the administration of medical policy and medical services for the health plan products that VNS CHOICE offers. He also oversees the medical utilization, quality management, grievances and appeals and evaluation of physician reimbursement models.
VNS Choice has several strengths; VNS Choice offers a varying range of home health care services which include management of chronic conditions, medical and nursing services. The Hospice Care program provides compassionate and skilled care for people who are at the end of their lives. The hospice services are available to patients who live at their homes, nursing homes or in the residence of VNS Choice. The organization is also home to a national research center where practical problems are solved and research is generated for the purpose of increasing knowledge that helps patients recover from illnesses that are short-term, to manage the challenging chronic conditions and to prepare effectively for advanced illnesses. Innovative research from the Center has enabled the center and attracted large amounts of grants from government and philanthropists. The people who reap these benefits are the VNS CHOICE patients and families.
The information generated from the Center’s research is shared with other clinical staff through national initiaves such as the CHAMP Program (Collaboration for Homecare Advances in Management and Practice). The CHAMP Program shares information on geriatric expertise with several home care agencies all over the US in order to promote quality home health care for the older generation. VNS Choice also shares results of research by publishing in professional and peer-reviewed journals, making presentations to students, professionals, the public and policy makers and also to the media to enhance coverage. The current strategy of the organization is to monitor research developments and changes in healthcare as well as changes in the demographics of patients such that patients receive the proper treatment in the setting that the patients prefer.
Working at VNC CHOICE
While working at VNS Choice, I was in the VNS CHOICE Community Care department, where I was reporting to the team manager. The purpose of the position was to provide care management through a process of assessment, planning, facilitation and advocating for options and services that can meet a patient’s health needs. The aim of the position was to maintain the members in the most independent living situation possible while ensuring that health care remains consistent throughout the health care continuum. The position also required close communication and collaboration with the primary care practitioners, family members and the interdisciplinary team. In the position of nurse consultant, the responsibilities included assessing, planning and providing intensive and continuous management across various settings ranging from home, acute and long-term care settings. It involved developing and negotiating care plans with patients, physicians and families. The nurse consultant assessed the patient’s living conditions, cultural influences and functioning. Other responsibilities included planning for the patient’s care, coordinating this care, assisting patients with daily living activities, providing nursing care, documenting services given, and evaluating the effectiveness of the plan of care formulated.
The work had several tasks associated with it. One of the major tasks was that of direct patient care which involved clinical assessment, administering medications and providing assistance with activities of daily living. This last task involved helping patients to position themselves, to move and lifting or transferring patients with different physical conditions sometimes with assistance and sometimes with out. The assistance could come from family members or paraprofessionals. Another task related to the health care of the members was transporting the medical equipment and supplies that would be required in delivery of nursing care from and to homes or care facilities and VNS Offices.
Participation in outreach activities that are aimed at promoting knowledge of the Program and its services is another task that was carried out by the nurse consultant. Some of the outreach activities included community health screening and in services and coordination of Program activities with those agencies outside the community and with health care providers. Closely related to this task is the development of programs that meet the specific needs of the selected patient population.
The major outputs of the position include nursing care plans that contain the nursing needs for the members and the objectives and goals of care. A budget of expected expenditure to indicate responsible fiscal spending that ensures all the necessary services are covered. Documentation of services rendered to the patient and their family is another of the outputs for the position. The documentation is done as per the standards of VNC CHOICE and the regulations of Managed Long Term Care and Licensed Home Care Services. A final output is the development of a program that meets the specialized needs of the patient population.
One of the major management actions that were required of the position was reduction of repeat hospital admissions for the patients. Return to hospital following discharge indicates a setback in the recovery of a patient (Ebersole, 2006). It also adds to the cost of healthcare (Boyce et al, 2007). To reduce this, the nurse consultant was required to plan for home care improvement initiatives, plan for a smooth transition from home to the hospital and to note the high-risk patients and manage them with the appropriate resources. Part of coordinating and ensuring a consistent continuum of health care is through having adequate home health aides, therapists and nurses to meet the needs of the patient population.
To meet the needs of the patients receiving home health care, I tried to assist the LVNS and health care aides who would be working with the patients who have dementia. The aim of the learning program was to assist the target group to develop competencies for care in dementia by using online teaching methods. The LVNs were chosen as they were the largest number of people dealing with the patients who required long term care. The health care aides were added to the group to ensure that there was a smooth transition for those patients who went back home and required the services of a health care aide from time. Because of the increase in the number of patients requiring geriatric care, the program was developed in such a way that the LVNs developed some kind of entrepreneurial bent. The point of this is to assist the spousal caregivers and other family caregivers to navigate through the complicated maze of multiproblem management. The program also had an aspect of soul-feeding and creativity that is still present in the brain of the elderly patient (Cohen, 2005). With this in mind, the nurse or healthcare aide delivers care with the knowledge that the elders can raise above loneliness, pain and chronic disorders to experience various phases of later life (Ebersole, 2006). These phases as described by Dr Cohen include midlife reevaluation, liberation, summing up and the encore phase (Cohen, 2005). The liberation phase includes a desire to innovate and experiment while the phase of summing up includes instances of life review, identification of legacies and resolution of conflicts (Cohen, 2005). The program was developed along Dolores Alford‘s model which gives a framework for the development of practice nurses who have some advanced training (Ebersole, 2006). The program thus while aiming at creating competencies for dementia care was also holistic as it tried to incorporate ways of meeting these needs for the elderly people. Geriatric nursing specialists explained the need for having nurses who are dispatched from nurse managed clinics and senior centers into the community to give guidance and counseling to caregivers.
Some difficulties were encountered in trying to implement this program. The budgetary appropriation for it was somewhat limited and not all the LVNs could benefit from the program. In addition, the normal resistance to change was there and the perception that learning the material would increase the nurses’ work was prevalent as a restraining force towards the adoption of the program. The time period in which to implement the program and measure its impact was short. To manage the difficulties above, the nurse manager in my department advised that I should have first conducted a needs assessment before launching the program as well as a force field analysis for change (Lewin, 1951). The aim of the analysis for change would have been to identify possible driving forces and restraining forces towards the change that I wanted to implement. Alternatively I could have applied the principles of adult learning more in the program, where the major principles that would have formed the basis for formulation of the program. The team manager also felt that Prochaska and Diclemente’s change theory would have served as a useful framework for introducing the learning program and ensuring its successful adoption by the nurses (Prochaska and Diclemente, 1985; Thomas, 1985). These would have ensured that the program dealt with the issues that the nurses felt were actually a problem in the department and that the solutions provided were solutions that could be practically implemented.
The program was not entirely thrown out but the team manager suggested that it could be fine tuned to the needs of the organization and the nurses. Additionally, the program would then be introduced to LVNs and the healthcare aides following a learning needs assessment that would be followed by a sensitization process that would make the nurses and health aides less resistant to change.
The financing for the program was also a problem so the team manager suggested that perhaps the LVNs and healthcare aides could not all be included in the program. Medicare could not finance the program as it finances long term care and services provided by nurses and health care aides (Geyer and Nayum, 1989). Medicare however does not cover care given at home. The deficit in funding arose because the program itself was not a service that affected the elderly directly. Medicaid would also not fund for the program as it funds long term care for those patients who are poor or may become poor from spending on long term care or medical care. Thus the team manager suggested that the program could start as a pilot program. The success of the pilot program will be crucial in increasing the buy-in for the program among the members of the executive team who can then authorize increases in spending towards the program. Medicaid has the provision for covering personal care given to members in their homes (Geyer and Nayum, 1989). However it still would not have covered the costs of implementation of the program.
VNS CHOICE gets its funding from Medicare, Medicaid and philanthropists. The grants from other sources make the out of pocket expenditure for VNS CHOICE. The teaching program would thus be funded from this hence the need to convince the executive team of the program’s positive effect and potential for increasing quality of care.
The practicum position was very relevant to the academic program I am currently undertaking. In delivery of long term health care, the use of the nursing process is very evident and cuts across the delivery of direct nursing care and the implementation of programs to increase awareness on long-term care and care for the elderly. This is evident from the need to assess and identify patient needs and manage them in a holistic manner with reference to the living conditions of the patient, their family support and the illnesses they may have.
The functions of management such as planning, organizing and controlling have also been very present during the practicum. Budgeting is an important component of nursing management. This has been made even clearer by the practicum experience. The experience provided an opportunity to see the nurse manager’s financial responsibility for maintaining fiscal health. The amount and quality of services delivered by nurses depends to a very large extent on budgetary plans (Swansburg, 1997). This makes it very necessary for nurse managers to be proficient at availing the necessary resources such that there is efficient use of resources that will facilitate delivery of effective and efficient care. Though the cost of nursing has always been recognized the income obtained from these services is usually included in bed and board in the budgeting process (Swansburg, 1997). Thus while basing nursing practice on the various functions of a nursing manager; I also identified an area that nurse managers would do well to explore with regard to the budgeting process. Achieving reimbursement for services provided by nurses by changing certain policies may lead to nurses being paid directly for services they have rendered depending on the skill of the person giving the care and the amount of care given (Geyer and Nyman, 1989). This may have the advantage of increasing the amount of money that can be redirected to meeting nurses learning needs and thus solving the problem of financing for education programs for nurses.
Other theories learnt that have been applicable to the practicum experience include the change theories which describe the process by which humans adopt change or respond to change. These theories have become more relevant and practical as their application has become apparent in efforts to get the LVNs and the health aides to participate in an educational program and apply the teachings of the education program to their practice.
Personal development and career choices
With regard to personal development, the practicum experience provided an opportunity for professional development. Some of the problems identified in trying to work in the department led to the development of better problem solving skills as well as organizational skills. The need to adhere to a budget also led to a better understanding of the role of the nurse manager in organizing and planning for resources within a healthcare unit setting. Additionally the practicum period provided for more opportunity to develop behavioral competencies such as proper documentation, patient teaching and the nursing process. In observing the nurse manager make corrections to my proposed program, I learnt several things about leadership such as constructive criticism, motivation and the role of leaders in building on the basic knowledge that those out of school have.
The practicum strengthened my decision to be involved in the delivery of health care in the community as opposed to an acute care hospital setting. I found the experience of working in the community to be more fulfilling as it made the concept of holistic care more applicable. Nursing care in the community cannot be complete without giving consideration to other components that affect health.