Nurses rated most trusted profession 13th straight year
As the American Nurses Association (ANA) embarks on a yearlong campaign to highlight the importance of nursing ethics and their impact on patients and health care quality, the annual Gallup survey on trust in professions shows the public continues to rate nursing as the most honest and ethical.
For the past 13 years, the public has voted nurses as the most honest and ethical profession in America in the Gallup poll. This year, 80 percent of Americans rated nurses’ honesty and ethical standards as “very high” or “high,” 15 percentage points above any other profession.
“All nurses share the critical responsibility to adhere to the highest ethical standards in their practice to ensure they provide superior health care to patients and society,” said ANA President Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN. “ANA is calling 2015 the Year of Ethics to highlight ethics as an essential component of everyday nursing practice and reinforce the trust patients have that nurses will protect their health and safety, and advocate on their behalf.”
As more Americans gain access to health care under the Affordable Care Act, consumers increasingly are finding that they can rely upon nurses to provide their preventive, wellness and primary care services.
Additionally, ANA has completed a revision of its Code of Ethics for Nurses, a cornerstone document of the nursing profession that upholds the best interests of patients, families and communities. The new Code reflects many changes and evolutions in health care and considers the most current ethical challenges nurses face in practice.
The new Code of Ethics for Nurses with Interpretive Statements will be released early in 2015. The revision involved a four-year process in which a committee received and evaluated comments on ethics issues from thousands of nurses.
Source: ANA News Release, December 18, 2014 ta
Post-Acute and Long Term Care Measures proposed by CMS
IMPACT Act of 2014
On September 18, 2014 Congress passed the Improving Medicare Post-Acute Care Transformation Act of 2014(the IMPACT Act) The Act requires the submission of standardized data by Long-Term Care Hospitals(LTCHs) Skilled Nursing Facilities (SNFs) Home Health Agencies (HHAs) and Inpatient Rehabilitation Facilities (IRFs).
The Act requires the reporting of standardized patient assessment measures with regard to quality measures, resource use, and other measures. Further it requires that the data elements be standardized so that they can be by all post-acute providers (standard nomenclature).
CMS is to develop and implement quality measures from five quality domains using standardized assessment data.
The quality measures are
- Skin integrity and changes in skin integrity
- Functional status, cognitive function, and changes in function and cognitive function
- Medication reconciliation
- Incidence of major falls
- Transfer of health information and care preferences when an individual transitions
- Resource use measures, including total estimated Medicare spending per beneficiary
- Discharge to community
- All-condition risk-adjusted potentially preventable hospital readmission rates
The targeted implementation dates for standardized patient assessment data are;
October 1, 2018
- Inpatient Rehabilitation Facilities (IRFs0
- Skilled Nursing Facilities (SNFs)
- Long Term Care Hospitals (LTCHs)
No later than January 1, 2019
- Home Healthcare Associations (HHAs)
The National Quality Forum is the organization assigned to develop these measures. The National Quality Forum (NQF) is a nonprofit organization that aims to improve the quality of healthcare for all Americans through fulfillment of its three-part mission: Setting national priorities and goals for performance improvement; Endorsing national consensus standards for measuring and publicly reporting on performance; and Promoting the attainment of national goals through education and outreach programs.
The Affordable Care Act (ACA) assigns new duties to NQF as the consensus-based entity, including convening multi-stakeholder groups to provide input to the Department of Health and Human Services on the selection of performance measures for public reporting and performance-based payment programs. To fulfill this role, NQF has established the Measure Applications Partnership (MAP).
The Measure Applications Partnership (MAP) will operate through a two tiered structure. An overarching, standing, multi-stakeholder Coordinating Committee will set the strategy for the Partnership and provide direction to, and ensure synchronization among, the advisory workgroups. The workgroups will advise the Coordinating Committee on measures needed for specific uses. The Coordinating Committee will provide input to HHS on measures for use in public reporting, performance-based payment, and other programs.
ARN’s response to these proposed measures is at the end of this update.
New 2015 ARN Health Policy Agenda
ARN’s health policy agenda is the cornerstone of ARN’s health policy and advocacy activities. The Health Policy Committee establishes these policy priorities on an annual basis and updates them as needed to reflect emerging issues. With the start of the 114th Congress, you will find that ARN has updated its health policy agenda quite a bit, which is a testament to the growth of ARN’s advocacy program. As usual, there are issues that ARN supports from a larger nursing community standpoint, such as increased funding for Title VIII and the National Institute for Nursing Research; however, you will also find more rehabilitation-specific legislation that we are either supporting or working on, such as implementation of the IMPACT Act. We also are continuing our involvement in regulatory matters, such as the Prospective Payment Systems for skilled nursing facilities, inpatient rehabilitation facilities, and home health, and any new developments in quality through either the Centers for Medicare & Medicaid Services or National Quality Forum.
Advocacy does not rest. Even when Congress is not in session in Washington, DC, members of Congress are in their home districts meeting with constituents. If Congress does not hear from rehabilitation nurses about the issues that are impacting the profession, then from whom will they hear it? ARN’s Standards and Scope of Rehabilitation Nursing (2014, p. 24) states, “the rehabilitation registered nurse advocates for patients and helps them develop skills so that they can advocate for themselves.”
Here are some easy ways to be involved
- Review the updated 2015 ARN Health Policy Agenda (coming soon)
- Respond to and distribute ARN Action Alerts.
- Utilize the legislative scorecard for Congress.
- Meet with your elected officials.
- Establish a relationship with elected officials and their staff.
- Call your members of Congress.
Advocacy Never Rests Jordan Wildermuth, MSW, Health Policy and Advocacy Manager
“I am of certain convinced that the greatest heroes are those who do their duty in the daily grind of domestic affairs whilst the world whirls as a maddening dreidel.” Florence Nightingale
If you have attended the Nurses in Washington Internship Program (NIWI) or been involved in any conversation about advocacy for the nursing profession, you have more than likely discussed the pivotal role that Florence Nightingale played as an advocate for nursing issues. The quote above is meant to serve as an affirmation of the important work rehabilitation nurses perform on a daily basis. While Congress works through world affairs that are “whirling like a maddening dreidel,” there are individuals that need to be cared for and improvements that need to be made. That is why ARN has a health policy agenda and engages members in advocacy, not only while Congress is in session but year round.
National Nurses Week May 6-12, 2015
Ethical practice. Quality care.
During National Nurses Week and throughout the year, ANA is proud to celebrate the role nurses play in delivering the highest level of quality care to their patients. The 2015 National Nurses Week theme "Ethical Practice. Quality Care." recognizes the importance of ethics in nursing and acknowledges the strong commitment, compassion and care nurses display in their practice and profession. The theme is an important part of ANA’s 2015 Year of Ethics outreach to promote and advocate for the rights, health and safety of nurses and patients.
Florence Nightingale Pledge This modified “Hippocratic Oath” was composed in 1893 by Mrs. Lystra E. Gretter and a Committee for the Farrand Training School for Nurses, Detroit, Michigan. It was called the Florence Nightingale Pledge as a token of esteem for the founder of modern nursing.
I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care.
RNF Grants Submission Deadline
Call for 2015 Conference Abstracts Now Open
Your participation is vital to the success of ARN’s Annual Educational Conference. Share your expertise with your ARN colleagues by presenting a paper, poster, or case study at the upcoming 2015 ARN Annual Educational Conference in New Orleans, LA. Submissions will be accepted from February 5, through April 3, 2015. Visit the ARN website for instructions on how to submit an abstract.
ARNs Response to the IMAPCT Measures
February 5, 2015
Glenn Hackbarth, JD Chairman
Medicare Payment Advisory Commission
425 Eye Street, NW, Suite 701
Washington, DC 20001
Dear Chairman Hackbarth,
On behalf of the Association of Rehabilitaton Nurses (ARN), I would like to communicate our grave concerns with the recommendation from the Commision’s January meeting to implement site-neutral payments for certain conditions. ARN represents over 5,600 rehabilitation nurses that work to enhance the quality of life for those affected by physical disability and/or chronic illness. ARN supports efforts to ensure patients with physical disabilities and/or chronic illnesses have access to comprehensive, quality care in the care setting most appropriate for them.
Rehabilitation nurses take a holistic approach to meeting patients’ nursing and medical, vocational, educational, environmental, and spiritual needs. Rehabilitation nurses begin to work with individuals and their families soon after the onset of a disabling injury or chronic illness. We provide continous support and care, including patient and family education, which empowers these individuals when they return home, or to work, or school. Additionally, rehabilitation nurses often teach patients and their caregivers how to access systems and resources.
Rehabilitation nursing is a philosophy of care, not a work setting or a phase of treatment. We base our practice on rehabilitative and restorative principles by: (1) managing complex medical issues; (2) collaborating with other specialists; (3) providing ongoing patient/caregiver education; (4) setting goals for maximum independence; and (5) establishing plans of care to maintain optimal wellness. Rehabilitation nurses practice in all settings, including freestanding inpatient rehabilitation facilities (IRFs), hospitals, long-term subacute care facilities/skilled nursing facilities (SNFs), long-term care hospitals (LTCHs), comprehensive outpatient rehabilitation facilities (CORFs), home health, and private practices.
While each post-acute care (PAC) setting serves as a valuable component of the care continuum, a determination of the need for intensive rehabilitation is dependent on the effects of a patient’s injury or illness (impairments, functional deficits, achievable goals), as opposed to the diagnosis.
Basing a site-neutral determination on an acute discharge-diagnosis-related group (DRG) prevents the assessment of function, an important component in determining the proper postacute setting. At the Commission’s most recent meeting, it was noted that among the conditions the Commission focused on, SNF and IRF patients had similar risk profiles and SNF patients were older and sicker. Commission Staff also mentioned SNFs are capable of treating medically complex patients, and noted that in markets without IRFs, they already do (Transcript page 57). ARN acknowledges that while medically complex patients are treated in SNFs, there is little evidence to support that SNFs are the most appropriate setting for such complex patients.
The conclusion from the Commission that IRF patients tend to be less frail than some other patients in other PAC settings because they tolerate and benefit from intensive therapy is not supported by evidence. Medicare requirements for inpatient rehabilitation hospitals/units (IRH/Us) are stringent and greatly differ from other post-acute care settings. Specifically, IRH/Us are licensed as hospitals and are required to provide close medical supervision by a physician with specialized training; 24-hour rehabilitation nursing; a multidisciplinary team approach; and intense daily therapy. SNFs, though an important part of rehabilitation care, are not required to provide the same level of staffing and services. In many instances, physicians only see patients on a monthly basis, and there is a lack of Registered Nurses (RNs) and more importantly Certified Registered Rehabilitation Nurses (CRRNs) present. In fact, the majority of services are provided by Licensed Practical Nurses (LPNs).
Failure to determine the patients’ appropriate site of care for post-acute services contributes to avoidable hospital readmissions. Patients’ clinically assessed needs should match the level of care determined by decision makers but often do not as a result of various factors, including geographic proximity and financial considerations. A 2006 study conducted by Deutsch et al entitled Poststroke Rehabilitation: Outcomes and Reimbursement of Inpatient Rehabilitation Facilities and Subacute Rehabilitation Programsi was acknowledged by the Commission during the January meeting. The study compared clinical outcomes among 58,000 stroke patients in both IRF and SNF settings. As noted by the Commission, the results indicated that for patients with minimal motor disabilities, there was no statistically significant difference in likelihood of discharge to a community setting whether the patients received their rehabilitation at an IRF or SNF. However, patients with mild cognitive disabilities and mild to significant motor disabilities had a greater likelihood of returning to a community setting if they received care in an IRF as opposed to a SNF. Additionally, as documented in the Dobson & DaVanzo (2014) study, over a two-year study period, patients with hip fractures who were treated in IRH/Us compared to those treated in SNFs, on average, returned home from their initial hospital rehabilitation stay 19 days earlier, remained home nearly two months longer (53 days), and stayed alive more than three months longer.ii For certain conditions, IRH/Us can lead to shorter lengths of stay, more frequent discharge of patients to the community, and have similar, if not lower, costs per episode of care. ARN emphasizes that in order to maximize the achievement of evidence-based quality outcomes, patients must receive the right care at the right time in the right setting.
Quality of care and outcomes of medical interventions also are important measures to consider when investigating methods to decrease healthcare spending. Such functional measures include:
- Medical stabilization (mortality rates);
- Returning the patient to a community setting or home (as opposed to sending the patient to long-term care, a nursing home, or another institutional setting);
- Restoring function (patient gains in functional abilities);
- Returning the patient to pre-impairment living activities (resuming work, caregiving activities, societal contributions, or reduced dependency for intensive health care services, such as nursing care and home health services); and Improving the patient’s quality of life.
The Commission’s conclusion at their most recent meeting that patients with select conditions who are treated in SNFs and IRFs often have similar outcomes is surprising. It is difficult to ascertain whether patients have similar outcomes upon discharge without a uniform functional assessment. IRF patient outcomes are measured with an inpatient rehabilitation facility patient assessment instrument (IRF-PAI) while SNF patient outcomes are measured using the minimum data set (MDS). Functional gains would be better compared if the assessments were performed using the same instrument. ARN urges the Commission to postpone the site-neutral policy recommendation until the Improving Medicare Post-Acute Care Transformation (IMPACT) Act is implemented, allowing for accurate functional outcome data to be compared in each setting.
The Commission also raised a concern regarding the IRF-PAI’s subjectivity, however, a process is in place to train and determine competency for rating the IRF-PAI; hence, a tendency to score incorrectly is not there as presumed.
We understand the desire to pursue post-acute care payment reforms; however, it is our belief that patients must have access to comprehensive, quality care in whichever care setting is most appropriate. ARN stands ready to work with you, your colleagues, and other stakeholders to engage in a thoughtful dialogue about these issues to ensure access to quality care for Medicare beneficiaries with physical disabilities and/or chronic disease. If you have any questions, please feel free to contact Jeremy Scott, ARN’s Health Policy Associate (202-230-5197 / firstname.lastname@example.org).
Sharon Murphy-Potts, BSN RN CRRN President
Attachment: The Essential Role of the Rehabilitation Nurse in Facilitating Care Transitions
- Deutsch, A., Granger, C.V., Heinemann, A.W., Fiedler, R.C., DeJong, G., Kane, R.L., Trevisan, M. (2006). Poststroke rehabilitation: Outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs. Stroke, 37(6), 1477–1482.
Dobson & DaVanzo. (2014). Assessment of Patient Outcomes of Rehabilitative Care Provided in Inpatient Rehabilitation Facilities (IRFs) and After Discharge. Retrieved January from www.amrpa.org
January 12, 2015
Measure Application Partnership National Quality Forum
1030 15th Street NW Suite 800
Washington DC 20005
Re: Pre-Rule Making Report for Post-Acute and Long-term Care Performance Measurement Programs
On behalf of the Association of Rehabilitation Nurses (ARN) – representing 5,700 rehabilitation nurses that work to enhance the quality of life for those affected by physical disability and/or chronic illness, we appreciate the opportunity to comment on the Pre-Rule Making Report for Post-Acute and Long-term Care Performance Measurement Programs.
ARN supports efforts to ensure people with physical disability and chronic illness have access to comprehensive, quality care in whichever care setting is most appropriate for them. Rehabilitation nurses take a holistic approach to meeting patients’ medical, vocational, educational, environmental, and spiritual needs. Rehabilitation nurses begin to work with individuals and their families soon after the onset of a disabling injury or chronic illness. We continue to provide support and care, including patient and family education, which empowers these individuals when they return home, to work, or to school. Rehabilitation nurses often teach patients and their caregivers how to access systems and resources.
Rehabilitation nursing is a philosophy of care, not a work setting or a phase of treatment. We base our practice on rehabilitative and restorative principles by: (1) managing complex medical issues; (2) collaborating with other specialists; (3) providing ongoing patient/caregiver education; (4) setting goals for maximum independence; and (5) establishing plans of care to maintain optimal wellness. Rehabilitation nurses practice in all settings, including freestanding rehabilitation facilities, hospitals, long-term subacute care facilities/skilled nursing facilities, inpatient rehabilitation facilities, long-term acute care facilities, comprehensive outpatient rehabilitation facilities, home health, and private practices, just to name a few.
E0141-Patient Fall Rate
ARN realizes that falls in a hospital and rehabilitation setting present significant risk for injury. All patients in rehabilitation are at risk of falling. In fact, studies indicate that the rate of falls for acute care is 3 -6 falls per 1000 patient days versus the rate for inpatient rehabilitation hospitals(IRF) vary between 2.92 – 17.8 falls per 1000 patient days (Gilewski, Roberts, Hirata & Riggs, 2007; Mayo, Korner-Bitensky, Becker & Georges, 1989). Thus IRFs have a higher rate just because of the nature of the type of patient being admitted. Patients admitted with a stroke, spinal cord injury, brain injury, amputations and neurologic impairments have demonstrated a higher fall rate than patients admitted to an IRF with cardiac, pulmonary and orthopedic disorders (Forrest, et al., 2012).
Furthermore, impulsivity is a common consequence of individuals with stroke and brain injury and can impede patient progress and recovery. Such cognitive impairment has been shown to be a leading risk factor for falls in older adults (Hitcho et al., 2004; Hong, Cho & Tak, 2010). Individuals with cognitive impairment are at a greater risk of injury from falling (Holtzer et al., 2007; Rochat et al., 2008). Staffing ratios may also affect fall rate as well. Some studies have shown that hospital units that had more than five patients per nurse had higher fall rates than units with five or fewer patients per nurse (Krauss et al., 2005).
Looking at falls rates without looking at all of the above mentioned components would not be helpful. There are many confounding factors that may not be able to give an adequate comparison for a pay for performance model. Therefore, falls benchmarks are not one size fits all. We request that the IRF fall rate consider these factors and compare IRF fall rates to only other IRFs. In addition, stratification and analysis of patient populations (stroke, brain injury, etc) would be helpful in providing additional insight and benchmarks.
IRF Functional Outcome Measure
The IRF Quality Reporting System could be greatly enhanced by further developing and expanding core measures such as mobility and self-care. ARN supports these indicators with the caveat that they are risk-adjusted and diagnosis/impairment group specific with definitive inclusion/exclusion criteria. While we support these indicators, we do not agree with the exclusion criteria for S2633-IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients. The exclusion criteria for S2633 are as follows:
3) Patients in coma, persistent vegetative state, complete teraplegia, and locked‐in syndrome are excluded, because they may have limited or less predictable self‐care improvement. 4) Patients younger than age 21.
Both of these criteria are inappropriate for use because they are not representative of the IRF setting. The patient population listed in Criteria #3 is not usually admitted/treated in an IRF and most IRFs treat patients younger than 21 if needed (the FIM instrument/IRF-PAI is for patients 7 and older).
S2510- SNF All
Cause 30 Day Post Discharge Readmission Measure
It is ARN’s understanding that it is the intention and desire of NQF to align measures across the post-acute care continuum when possible. However, there are different measures for the different PAC venues including IRH/Us and SNFs. Measure 2502, All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Inpatient Rehabilitation Facilities (IRFs) is based on data for 24 months of IRF discharges to non-hospital post-acute levels of care or to the community while measure 2510, Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) is based on 12 months of data. There should not be such disconnect if the original intent of NQF’s recommendation and selection of measures was to be both harmonious and parsimonious. We would encourage the committee to examine the measures across the PAC continuum for opportunities for alignment.
While we appreciate the work of the committee, we strongly disagree with the exclusion criteria for SNF stays where the patient had one or more intervening post-acute care (PAC) admissions to an IRF which occurred either between the prior proximal hospital discharge and SNF admission or after the SNF discharge, within the 30-day risk window. The exclusion criteria would not take into account a medically complex patient that is treated in an IRF and then readmitted within 30 days for an issue that may have been treated as a co-morbidity. We believe that IRFs should be considered a proximal hospitalization and disagree with the rationale provided for exclusion, that these patients are clinically different.
As determined in a recent OIG report, the readmission rate for SNFs is both problematic and concerning. The report found that an estimated 22 percent of Medicare beneficiaries experienced adverse events during their SNF stays and an additional 11 percent of Medicare beneficiaries experienced temporary harm events during their SNF stays. Over half of the residents who experienced harm returned to a hospital for treatment, with an estimated cost to Medicare of $208 million in August 2011. This equates to $2.8 billion spent on hospital treatment for harm caused in SNFs in FY 2011 (OIG, 2014). Readmission rates for IRFs do vary but are nowhere near the SNF rate. A study by Ottenbacher et al. (2012, 2014) found that the 30-day readmission rates for the six largest diagnostic impairment categories (stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders and brain dysfunction) was 11.8 percent with 50 percent of readmissions occurring within 11 days of discharge from the IRF.
We also disagree with the 30-day readmission data utilized from claims data. Determining readmission rates will be difficult for IRFs or other post-acute settings to discern as claims data are cumbersome to use and access. Utilizing this indicator will not provide meaningful insight or have an impact on quality improvement efforts if the settings do not have access to the data.
While we appreciate the work of the committee, we are disappointed in the lack of awareness of the current processes in IRFs. ARN recommends that the LTC/PAC workgroup consist of members with additional insight and a greater understanding into the specialty of rehabilitation. We also encourage NQF to publish and respond to each comment (similar to CMS) versus summarizing so as not to omit or skew what is being addressed/commented on.
Sharon Murphy-Potts, BSN RN CRRN President ARN