New Jersey Nurse New Jersey Nurse Delegation Pilot Delegation Pilot

ProgramProgramWilliam A. B. DittoWilliam A. B. Ditto

DirectorDirector

Division of Disability ServicesDivision of Disability Services

New Jersey Department of Human New Jersey Department of Human ServicesServices

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Overview of PresentationOverview of Presentation

Why Pursue Nurse Delegation in Why Pursue Nurse Delegation in Home Care?Home Care?

What is the Status of Nurse What is the Status of Nurse Delegation in NJ?Delegation in NJ?

The Nurse Delegation ProcessThe Nurse Delegation Process Design of the NJ Pilot Delegation Design of the NJ Pilot Delegation

Program: “There’s No Place Like Program: “There’s No Place Like Home”Home”

Some Early FindingsSome Early Findings

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Why Did NJ Pursue This?Why Did NJ Pursue This?

DemographicsDemographics EconomicsEconomics Support to unpaid Family CaregiversSupport to unpaid Family Caregivers Better use of professional nursing Better use of professional nursing

personnel in home care agenciespersonnel in home care agencies Patient SafetyPatient Safety Acknowledge home health aide skills Acknowledge home health aide skills

& talents & talents

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Why Did NJ Undertake this Why Did NJ Undertake this Project?Project?

Individuals are in nursing facilities who Individuals are in nursing facilities who want to be in the community or with familywant to be in the community or with family

Families find that home care aides cannot Families find that home care aides cannot provide the type of service they need to provide the type of service they need to maintain loved ones at home maintain loved ones at home

There is a shortage of licensed nursing There is a shortage of licensed nursing personnel personnel

Demand for home care will escalate Demand for home care will escalate dramatically as the “boomers” begin dramatically as the “boomers” begin needing LTC servicesneeding LTC services

It has been effective in other statesIt has been effective in other states NJ must address its “Olmstead” obligationNJ must address its “Olmstead” obligation

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Why Did NJ Undertake this Why Did NJ Undertake this Project? Project? (continued)(continued)

Family caregivers “burn out” or risk loss Family caregivers “burn out” or risk loss of employment because of care giving of employment because of care giving and need to perform “skilled tasks” and need to perform “skilled tasks”

We are not making full use of the skills, We are not making full use of the skills, knowledge and talent of registered knowledge and talent of registered professional nurses who work in the professional nurses who work in the Medicaid PCA programMedicaid PCA program

We know (but never acknowledge) that We know (but never acknowledge) that aides are performing skilled tasks aides are performing skilled tasks without nursing oversight or supervisionwithout nursing oversight or supervision

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Nurse Delegation in New Nurse Delegation in New JerseyJersey

In New Jersey, after assessing a In New Jersey, after assessing a consumer’s condition and the consumer’s condition and the competencies of unlicensed competencies of unlicensed assistive personnel, nurses may assistive personnel, nurses may “delegate selected nursing tasks” to “delegate selected nursing tasks” to unlicensed persons.unlicensed persons.

There are no specific restrictions on There are no specific restrictions on the tasks that may be delegated, the tasks that may be delegated, provided the task does not require provided the task does not require the knowledge and judgment of a the knowledge and judgment of a nurse .nurse .

Source: NJAC 13:37-6.2 – (State Board of Nursing Regulations)Source: NJAC 13:37-6.2 – (State Board of Nursing Regulations)

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Restrictions on Delegation Restrictions on Delegation to Certified Home Health to Certified Home Health

Aides in NJAides in NJ Current rules regarding certified home Current rules regarding certified home

health aides (CHHA) prohibit them health aides (CHHA) prohibit them from administering medications (NJAC from administering medications (NJAC 13:37-14.3)13:37-14.3)

This prevents nurses from delegating This prevents nurses from delegating this task to CHHAs because the aide this task to CHHAs because the aide cannot accept the delegation.cannot accept the delegation.(Nurses can delegate this task to other (Nurses can delegate this task to other

Unlicensed Assistive Personnel (UAP) Unlicensed Assistive Personnel (UAP) at present in other care at present in other care environments, e.g.. hospital, assisted environments, e.g.. hospital, assisted living facility.)living facility.)

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Exemption for Delegation Exemption for Delegation in New Jersey’s Pilot in New Jersey’s Pilot

GrantedGranted The State Board of Nursing The State Board of Nursing

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

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Delegation – Dealing Delegation – Dealing with Issueswith Issues

Issues that can be barriers to delegation:Issues that can be barriers to delegation: Process of delegation—clarified in rule with Process of delegation—clarified in rule with

forms provided so that nurses know they have forms provided so that nurses know they have documented needed items.documented needed items.

Liability issues—language protecting nurses Liability issues—language protecting nurses from situations where aides do not follow their from situations where aides do not follow their instructions.instructions.

Authority of nurse only to delegate—nurses, Authority of nurse only to delegate—nurses, rather than their employers, retain the rather than their employers, retain the authority to decide where delegation is authority to decide where delegation is appropriate.appropriate.

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Pilot “Drivers”Pilot “Drivers” Home care agencies indicated that providing Home care agencies indicated that providing

“intermittent” skilled care several times a “intermittent” skilled care several times a day by licensed nurses is not practical or day by licensed nurses is not practical or realistic in the current environmentrealistic in the current environment

Skilled nursing care at home identified as a Skilled nursing care at home identified as a crucial element for facilitating crucial element for facilitating deinstitutionalization, by NJ Olmstead deinstitutionalization, by NJ Olmstead Stakeholder Task Force (2001)Stakeholder Task Force (2001)

NJ had a federal “Real Choice Systems NJ had a federal “Real Choice Systems Change Grant” and could use funds to Change Grant” and could use funds to explore Nurse Delegation as an innovative explore Nurse Delegation as an innovative practicepractice

Consumers wanted to stay at home with careConsumers wanted to stay at home with care

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A Review of theA Review of the Delegation Delegation ProcessProcess

PCA Pilot agency nurses, who have been PCA Pilot agency nurses, who have been oriented, review new referrals and current oriented, review new referrals and current caseloads and determine which consumers caseloads and determine which consumers would benefit from delegated serviceswould benefit from delegated services

The decision to delegate or not and to rescind The decision to delegate or not and to rescind delegation is the sole responsibility of the delegation is the sole responsibility of the nurse based on his/her professional judgment.nurse based on his/her professional judgment.

The RN uses The RN uses triad model of delegationtriad model of delegation -- one -- one nurse delegates tasks to one aide for one nurse delegates tasks to one aide for one consumer. Task competency of the CHHA is consumer. Task competency of the CHHA is not transferable from one consumer to another, not transferable from one consumer to another, even if the nurse and aide are the same for even if the nurse and aide are the same for other consumers. Must be patient specific. other consumers. Must be patient specific. Each skilled task requires an individual Each skilled task requires an individual delegation.delegation.

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A Review of theA Review of the Delegation Delegation ProcessProcess

The RN has the right to refuse to delegate The RN has the right to refuse to delegate tasks of nursing care if he/she believes it tasks of nursing care if he/she believes it would be unsafe or inappropriate to would be unsafe or inappropriate to delegate or he/she is unable to provide delegate or he/she is unable to provide adequate supervision.adequate supervision.

Decisions relative the frequency of Decisions relative the frequency of supervision and reinforcement of the supervision and reinforcement of the performance of delegated tasks is the performance of delegated tasks is the domain of the front line (delegating) domain of the front line (delegating) nurse.nurse.

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Nurse Delegation PilotNurse Delegation PilotResearch & Development Research & Development

PhasePhase Series of Meetings & Forums with Board Series of Meetings & Forums with Board

of Nursing, Consumers, Home Care of Nursing, Consumers, Home Care Agencies & Associations, CHHAs and Agencies & Associations, CHHAs and Insurance CarriersInsurance Carriers

Review of Similar Projects in Other Review of Similar Projects in Other States and Research FindingsStates and Research Findings

Under contract to the Division, Rutgers Under contract to the Division, Rutgers University designed a model “pilot” University designed a model “pilot” program for Nurse Delegation in NJprogram for Nurse Delegation in NJ

Pilot Evaluation Component also was Pilot Evaluation Component also was developed bydeveloped by Rutgers University (Center Rutgers University (Center for State Health Policy)for State Health Policy)

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Nurse Delegation Pilot Nurse Delegation Pilot Study PopulationStudy Population

Study population consists of individuals Study population consists of individuals eligible for Medicaid personal care assistant eligible for Medicaid personal care assistant (PCA) services(PCA) services

Does not impact on (or negate) the receipt Does not impact on (or negate) the receipt of any other Medicaid services of any other Medicaid services

Intended to address the needs of individuals Intended to address the needs of individuals with relatively stable conditions who require with relatively stable conditions who require ongoing PCA service in the communityongoing PCA service in the community

PCA recipients may have their authorized PCA recipients may have their authorized hours increased when they enter delegation hours increased when they enter delegation pilot to account for aide training or pilot to account for aide training or expanded serviceexpanded service

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NJ NURSE DELEGATION PILOT NJ NURSE DELEGATION PILOT Design FeaturesDesign Features

Board of Nursing agreed to allow Board of Nursing agreed to allow medication administration by Certified medication administration by Certified Home Health Aides for duration of the Home Health Aides for duration of the pilotpilot

DDS/DHS selected 21 Home Care DDS/DHS selected 21 Home Care Companies with 49 locations to Companies with 49 locations to participate in the pilot on a voluntary participate in the pilot on a voluntary basisbasis

Target is to have 200-300 individuals who Target is to have 200-300 individuals who will receive nurse delegated services over will receive nurse delegated services over 2-3 year period2-3 year period

Participation is VOLUNTARY for everyoneParticipation is VOLUNTARY for everyone

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NJ Nurse Delegation NJ Nurse Delegation PilotPilot

Design Features (continued)Design Features (continued) Delegating nurses (and agency Delegating nurses (and agency

administrators) have been oriented about administrators) have been oriented about the process of delegation, using the State the process of delegation, using the State Board of Nursing Delegation AlgorithmBoard of Nursing Delegation Algorithm

Agency field nurses identify potential Agency field nurses identify potential participants in their caseloadsparticipants in their caseloads

The Division works with the Community The Division works with the Community Choice Counselors, at the NJ Department Choice Counselors, at the NJ Department of Health & Senior Services, to identify of Health & Senior Services, to identify individuals presently in nursing facilities individuals presently in nursing facilities who could transition out if delegated who could transition out if delegated services are made availableservices are made available

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NJ Nurse Delegation NJ Nurse Delegation PilotPilot

Design Features (continued)Design Features (continued) Home care agency’s delegating nurses have Home care agency’s delegating nurses have

the “final say” in all matters related to the “final say” in all matters related to delegationdelegation

Participants, agencies and nurses are asked Participants, agencies and nurses are asked to cooperate with researchers in both to cooperate with researchers in both allowing interviews and providing data.allowing interviews and providing data.

A unique Medicaid PCA procedure code and A unique Medicaid PCA procedure code and rate have been developed to cover the cost rate have been developed to cover the cost of the nurse delegation service. As of the nurse delegation service. As mentioned the recipients authorized hours mentioned the recipients authorized hours may be increased temporarily for training or may be increased temporarily for training or longer term because a new task has been longer term because a new task has been added for the aide (ongoing)added for the aide (ongoing)

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Delegation for Participants Delegation for Participants CurrentlyCurrently

in Nursing Facilities in Nursing Facilities Department of Health & Senior Services (DHSS) Department of Health & Senior Services (DHSS)

staff identify, with NF staff, potential candidates staff identify, with NF staff, potential candidates who wish to live in the community and are who wish to live in the community and are appropriate for the Pilot study during discharge appropriate for the Pilot study during discharge planning sessions.planning sessions.

Using the list of participating Pilot PCA agencies, Using the list of participating Pilot PCA agencies, DHSS staff invite a local PCA agency to attend a DHSS staff invite a local PCA agency to attend a meeting with the potential participant, family and meeting with the potential participant, family and other advocates to review the efficacy of other advocates to review the efficacy of delegation services when discharged.delegation services when discharged.

Pilot staff have also conducted training sessions Pilot staff have also conducted training sessions with discharge planners in hospitals and nursing with discharge planners in hospitals and nursing facilities to make them aware of the expanded facilities to make them aware of the expanded service.service.

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NJ Pilot Program Oversight NJ Pilot Program Oversight & Reporting& Reporting

An Advisory Council, made up of a cross section An Advisory Council, made up of a cross section of stakeholders, is in place to provide advice of stakeholders, is in place to provide advice and assist with problem solving. The Advisory and assist with problem solving. The Advisory Council meets 2-3 times per year. As the needs Council meets 2-3 times per year. As the needs of the management team change over the life of of the management team change over the life of the pilot, so does the membership of the the pilot, so does the membership of the Advisory Council.Advisory Council.

Periodic updates are issued to keep the home Periodic updates are issued to keep the home care industry, not involved in the pilot, care industry, not involved in the pilot, informed of the progress and outcomes of the informed of the progress and outcomes of the pilot.pilot.

A bi-monthly report is being generated for the A bi-monthly report is being generated for the Board of NursingBoard of Nursing

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Funding Funding

The Division applied for and received multi-The Division applied for and received multi-year funding from the Robert Wood Johnson year funding from the Robert Wood Johnson Foundation (RWJF) to operate the pilot for a 36 Foundation (RWJF) to operate the pilot for a 36 month period.month period.

RWJF funds are matched with Title XIX RWJF funds are matched with Title XIX (Medicaid) funding to provide adequate (Medicaid) funding to provide adequate resources.resources.

Discussions with the Assistant Secretary for Discussions with the Assistant Secretary for Evaluation & Planning (ASPE) at federal DHHS Evaluation & Planning (ASPE) at federal DHHS resulted in additional funding being provided resulted in additional funding being provided for the evaluation of cost effectiveness by for the evaluation of cost effectiveness by Mathematica Policy Research of PrincetonMathematica Policy Research of Princeton

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Some Early Findings in Some Early Findings in NJNJ

21 Home Care companies 21 Home Care companies participating with 44 sitesparticipating with 44 sites

186 registered nurses completed the 186 registered nurses completed the orientation programorientation program

210 individual Medicaid clients have 210 individual Medicaid clients have received delegated servicesreceived delegated services

150 patients are active in the 150 patients are active in the program as of Februaryprogram as of February

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Some Early Findings in Some Early Findings in NJNJ

Medication administration is the most Medication administration is the most requested service (February 2010)requested service (February 2010) 132 medication administration 132 medication administration

delegationsdelegations 106 Oral106 Oral 9 Injectable9 Injectable 9 Topical 9 Topical 6 Other Routes6 Other Routes

24 Blood Glucose Monitoring24 Blood Glucose Monitoring

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Some Early Findings in Some Early Findings in NJNJ

Other Delegated Tasks (25)Other Delegated Tasks (25) Gastronomy Tube FeedsGastronomy Tube Feeds Catheterization, bladder & bowel Catheterization, bladder & bowel

programsprograms Wound CareWound Care Insulin pre fillInsulin pre fill Cough assistCough assist

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Long Range GoalsLong Range Goals Add options for individuals to remain at Add options for individuals to remain at

home & in the community or to leave a home & in the community or to leave a nursing facility.nursing facility.

Address the Olmstead decision Address the Olmstead decision mandates.mandates.

Inform changes in the State Board of Inform changes in the State Board of Nursing Regulations to support Nursing Regulations to support delegated medication administration by delegated medication administration by home health aides.home health aides.

Make better use of existing home care Make better use of existing home care provider agency services.provider agency services.

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For further information:For further information:

Contact:Contact:

Susan Brennan McDermott, RNSusan Brennan McDermott, RN

Project ManagerProject Manager

NJ Nurse Delegation Pilot NJ Nurse Delegation Pilot

609 292-1268609 292-1268

Susan.Brennan-Susan.Brennan-McDermott@dhs.state.nj.usMcDermott@dhs.state.nj.us