New Jersey Nurse Delegation Pilot Program

1
New Jersey Nurse Delegation Pilot Program

• William A. B. Ditto
• Director
• Division of Disability Services
• New Jersey Department of Human Services

2
Overview of Presentation

• Why Pursue Nurse Delegation in Home Care?
• What is the Status of Nurse Delegation in NJ?
• The Nurse Delegation Process
• Design of the NJ Pilot Delegation Program
  Theres No Place Like Home
• Some Early Findings

3
Why Did NJ Pursue This?

• Demographics
• Economics
• Support to unpaid Family Caregivers
• Better use of professional nursing personnel in
  home care agencies
• Patient Safety
• Acknowledge home health aide skills talents

4
Why Did NJ Undertake this Project?

• Individuals are in nursing facilities who want to
  be in the community or with family
• Families find that home care aides cannot provide
  the type of service they need to maintain loved
  ones at home
• There is a shortage of licensed nursing personnel
  
• Demand for home care will escalate dramatically
  as the boomers begin needing LTC services
• It has been effective in other states
• NJ must address its Olmstead obligation

5
Why Did NJ Undertake this Project? (continued)

• Family caregivers burn out or risk loss of
  employment because of care giving and need to
  perform skilled tasks
• We are not making full use of the skills,
  knowledge and talent of registered professional
  nurses who work in the Medicaid PCA program
• We know (but never acknowledge) that aides are
  performing skilled tasks without nursing
  oversight or supervision

6
Nurse Delegation in New Jersey

• In New Jersey, after assessing a consumers
  condition and the competencies of unlicensed
  assistive personnel, nurses may delegate
  selected nursing tasks to unlicensed persons.
• There are no specific restrictions on the tasks
  that may be delegated, provided the task does not
  require the knowledge and judgment of a nurse .
• Source NJAC 1337-6.2 (State Board of Nursing
  Regulations)

7
Restrictions on Delegation to Certified Home
Health Aides in NJ

• Current rules regarding certified home health
  aides (CHHA) prohibit them from administering
  medications (NJAC 1337-14.3)
• This prevents nurses from delegating this task to
  CHHAs because the aide cannot accept the
  delegation.
• (Nurses can delegate this task to other
  Unlicensed Assistive Personnel (UAP) at present
  in other care environments, e.g.. hospital,
  assisted living facility.)

8
Exemption for Delegation in New Jerseys Pilot
Granted

• The State Board of Nursing issued a letter of
  support on October 22, 2008 allowing medication
  administration by CHHAS within the parameters of
  the pilot to help inform regulatory changes by
  the Board of Nursing in the future.

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Delegation Dealing with Issues

• Issues that can be barriers to delegation
• Process of delegationclarified in rule with
  forms provided so that nurses know they have
  documented needed items.
• Liability issueslanguage protecting nurses from
  situations where aides do not follow their
  instructions.
• Authority of nurse only to delegatenurses,
  rather than their employers, retain the authority
  to decide where delegation is appropriate.

10
Pilot Drivers

• Home care agencies indicated that providing
  intermittent skilled care several times a day
  by licensed nurses is not practical or realistic
  in the current environment
• Skilled nursing care at home identified as a
  crucial element for facilitating
  deinstitutionalization, by NJ Olmstead
  Stakeholder Task Force (2001)
• NJ had a federal Real Choice Systems Change
  Grant and could use funds to explore Nurse
  Delegation as an innovative practice
• Consumers wanted to stay at home with care

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A Review of the Delegation Process

• PCA Pilot agency nurses, who have been oriented,
  review new referrals and current caseloads and
  determine which consumers would benefit from
  delegated services
• The decision to delegate or not and to rescind
  delegation is the sole responsibility of the
  nurse based on his/her professional judgment.
• The RN uses triad model of delegation -- one
  nurse delegates tasks to one aide for one
  consumer. Task competency of the CHHA is not
  transferable from one consumer to another, even
  if the nurse and aide are the same for other
  consumers. Must be patient specific. Each
  skilled task requires an individual delegation.

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A Review of the Delegation Process

• The RN has the right to refuse to delegate tasks
  of nursing care if he/she believes it would be
  unsafe or inappropriate to delegate or he/she is
  unable to provide adequate supervision.
• Decisions relative the frequency of supervision
  and reinforcement of the performance of delegated
  tasks is the domain of the front line
  (delegating) nurse.

13
Nurse Delegation PilotResearch Development
Phase

• Series of Meetings Forums with Board of
  Nursing, Consumers, Home Care Agencies
  Associations, CHHAs and Insurance Carriers
• Review of Similar Projects in Other States and
  Research Findings
• Under contract to the Division, Rutgers
  University designed a model pilot program for
  Nurse Delegation in NJ
• Pilot Evaluation Component also was developed by
  Rutgers University (Center for State Health
  Policy)

14
Nurse Delegation Pilot Study Population

• Study population consists of individuals eligible
  for Medicaid personal care assistant (PCA)
  services
• Does not impact on (or negate) the receipt of any
  other Medicaid services
• Intended to address the needs of individuals with
  relatively stable conditions who require ongoing
  PCA service in the community
• PCA recipients may have their authorized hours
  increased when they enter delegation pilot to
  account for aide training or expanded service

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NJ NURSE DELEGATION PILOT Design Features

• Board of Nursing agreed to allow medication
  administration by Certified Home Health Aides for
  duration of the pilot
• DDS/DHS selected 21 Home Care Companies with 49
  locations to participate in the pilot on a
  voluntary basis
• Target is to have 200-300 individuals who will
  receive nurse delegated services over 2-3 year
  period
• Participation is VOLUNTARY for everyone

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NJ Nurse Delegation PilotDesign Features
(continued)

• Delegating nurses (and agency administrators)
  have been oriented about the process of
  delegation, using the State Board of Nursing
  Delegation Algorithm
• Agency field nurses identify potential
  participants in their caseloads
• The Division works with the Community Choice
  Counselors, at the NJ Department of Health
  Senior Services, to identify individuals
  presently in nursing facilities who could
  transition out if delegated services are made
  available

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NJ Nurse Delegation PilotDesign Features
(continued)

• Home care agencys delegating nurses have the
  final say in all matters related to delegation
• Participants, agencies and nurses are asked to
  cooperate with researchers in both allowing
  interviews and providing data.
• A unique Medicaid PCA procedure code and rate
  have been developed to cover the cost of the
  nurse delegation service. As mentioned the
  recipients authorized hours may be increased
  temporarily for training or longer term because a
  new task has been added for the aide (ongoing)

18
Delegation for Participants Currently in Nursing
Facilities

• Department of Health Senior Services (DHSS)
  staff identify, with NF staff, potential
  candidates who wish to live in the community and
  are appropriate for the Pilot study during
  discharge planning sessions.
• Using the list of participating Pilot PCA
  agencies, DHSS staff invite a local PCA agency to
  attend a meeting with the potential participant,
  family and other advocates to review the efficacy
  of delegation services when discharged.
• Pilot staff have also conducted training sessions
  with discharge planners in hospitals and nursing
  facilities to make them aware of the expanded
  service.

19
NJ Pilot Program Oversight Reporting

• An Advisory Council, made up of a cross section
  of stakeholders, is in place to provide advice
  and assist with problem solving. The Advisory
  Council meets 2-3 times per year. As the needs
  of the management team change over the life of
  the pilot, so does the membership of the Advisory
  Council.
• Periodic updates are issued to keep the home care
  industry, not involved in the pilot, informed of
  the progress and outcomes of the pilot.
• A bi-monthly report is being generated for the
  Board of Nursing

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Funding

• The Division applied for and received multi-year
  funding from the Robert Wood Johnson Foundation
  (RWJF) to operate the pilot for a 36 month
  period.
• RWJF funds are matched with Title XIX (Medicaid)
  funding to provide adequate resources.
• Discussions with the Assistant Secretary for
  Evaluation Planning (ASPE) at federal DHHS
  resulted in additional funding being provided for
  the evaluation of cost effectiveness by
  Mathematica Policy Research of Princeton

21
Some Early Findings in NJ

• 21 Home Care companies participating with 44
  sites
• 186 registered nurses completed the orientation
  program
• 210 individual Medicaid clients have received
  delegated services
• 150 patients are active in the program as of
  February

22
Some Early Findings in NJ

• Medication administration is the most requested
  service (February 2010)
• 132 medication administration delegations
• 106 Oral
• 9 Injectable
• 9 Topical
• 6 Other Routes
• 24 Blood Glucose Monitoring

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Some Early Findings in NJ

• Other Delegated Tasks (25)
• Gastronomy Tube Feeds
• Catheterization, bladder bowel programs
• Wound Care
• Insulin pre fill
• Cough assist

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Long Range Goals

• Add options for individuals to remain at home
  in the community or to leave a nursing facility.
• Address the Olmstead decision mandates.
• Inform changes in the State Board of Nursing
  Regulations to support delegated medication
  administration by home health aides.
• Make better use of existing home care provider
  agency services.

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For further information

• Contact
• Susan Brennan McDermott, RN
• Project Manager
• NJ Nurse Delegation Pilot
• 609 292-1268
• Susan.Brennan-McDermott_at_dhs.state.nj.us