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: “There’s 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 consumer’s 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 13:37-6.2 – (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 13:37-14.3) • 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 Jersey’s Pilot Granted • The State Board of Nursing issued a letter of support on October 22, 2008 allowing medication administration by CHHA’S within the parameters of the pilot to help inform regulatory changes by the Board of Nursing in the future.

9. Delegation – Dealing with Issues Issues that can be barriers to delegation: • Process of delegation—clarified in rule with forms provided so that nurses know they have documented needed items. • Liability issues—language protecting nurses from situations where aides do not follow their instructions. • Authority of nurse only to delegate—nurses, 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

11. 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.

12. 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 byRutgers 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

15. 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

16. 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

17. NJ Nurse Delegation PilotDesign Features (continued) • Home care agency’s 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

20. 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

23. Some Early Findings in NJ • Other Delegated Tasks (25) • Gastronomy Tube Feeds • Catheterization, bladder & bowel programs • Wound Care • Insulin pre fill • Cough assist

24. 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.

25. For further information: • Contact: Susan Brennan McDermott, RN Project Manager NJ Nurse Delegation Pilot 609 292-1268 Susan.Brennan-McDermott@dhs.state.nj.us