Cheryl Boldt, RN

Transitional Medicare Units as distinct parts in Long Term Care are back. Distribution of residents with post-hospitalization service needs have acuity levels and documentation needs which are indeed difficult to meet if the residents are spread throughout the facility. This does not usually become noticeable until a Medicare a census becomes approximately 10-15% of the overall census. Medicare requirements and the philosophy of rehab transitional care are a challenge to teach to all of the staff in your organization. The admission and discharge process, complexity of care and treatment, communication, documentation, assessment, education, MDS completion, and Care Planning needs and multi-family member presences are more intense. The traditional model of a “Charge Nurse” or “Wing Nurse” working with a group of C.N.A.’s needs to be altered to accommodate transitional care. Portraying your Unit as a transitional unit to your customers from the beginning is critical.

The most frequently used nursing staffing model is one referred to as Primary Teaming. A licensed nurse teams with a C.N.A. and they are usually responsible for an “average” of 10-12 residents. The issue of assigning a “same” number of residents to each Primary Team needs clarification. Assignments must consider acuity. Acuity is not always “just” related to medical complexity or ADL assist. Keep in mind a difficult family member or a resident who has behavioral issues requires as much time as medical complexity or more. Therefore, the first day a team comes to work and has 8 residents and the other team may have 14 is usually an interesting dialogue. Cries of “it’s not fair” will usually be heard. The front line needs to have frank discussion to work through the understanding that numbers alone cannot drive assignments. Geographically, the resident assignment needs to make sense also. It is critical the staff on the unit understand the approach of assignments based on acuity.

The role of this nurse on this primary team is as a partner in direct care of the residents assigned with the C.N.A., and the direct supervisor of this C.N.A they are assigned with. Other duties include medication administration and monitoring the effects and side effects, treatments, skin documentation including the measuring of pressure ulcers (including WITH the wound team weekly- another article), Admission of the resident, education of the resident and family, assessing/inspecting and documenting to support skilled care need, notification of MD and family of any change in condition, noting MD orders, documenting to support the MDS, care planning and attending care conferences, updating of Pocket Care Guides, giving and getting shift report with the C.N.A., communicating with other departments about changes in the plan of care, change of shift rituals such as Narc counts and MAR cross-checks, etc., Discharge of the resident, carrying out Restorative Nursing Programs with the C.NA., etc.

Usually the day and evening shift requires the same ratio of one nurse and one C.N.A. for 10-12 residents. The reason for this is admissions usually arrive later in the day, many phone calls come in after families get off work, and there are many return calls from MDs at the end of the day, fewer department managers are available as a resource. The night shift requires half of the staffing of these other shifts. If you have 12 hour shifts, beware of reducing your staffing by half at 7pm or 7:30 pm if admissions are arriving in the late afternoons or in the evening. This is our chance to make a good first impression, and time spent getting the new resident off to a good start is well worth the cost of labor. The first impression and first 72 hours experience are directly related to the appropriate length of stay. A resident who is having a bad experience wants “out” as soon as possible.

The utilization of RN’s or LPN’s/LVN’s is dependent on the type of residents admitted and the scope of services provided. Medicare requires 8 hours of RN coverage daily. Obviously if a resident has a care need that can only be provided by an RN, you must make certain an RN performs that service. Please check with your state’s requirements for RN coverage daily as well as the Scope of Practice for LPN’s/LVN’s. Be prepared to “think differently” about the Nursing Model on this Transitional Care Unit.