In this model, which is the only fully developed model, an APN-GCM contracts with an elderly patient and/or family caregiver to provide care management services for an agreed-upon fee (e.g., an hourly rate or retainer). GCM services are usually for crisis patients in need of advanced health care management or for patients who require manage- ment of their long-term care needs so they can remain in their homes, if they are ill or disabled. Patients might be in need of APN-GCM ser- vices that allow them to be discharged home safely (following a hospi- talization, rehabilitation, or skilled nursing home stay), with their short- and long-term needs appropriately coordinated.
18
New Practice Models
for APNs: Thinking
Outside the Box
NEW PRACTICE MODELS FOR APNS! THINKING OUTSIDE THE BOX 19
Why Offer GCM Services?
• Most elderly people want to be in their home (as long as possi- ble) even if they require long-term care services. Giving these patients a choice results in better compliance and a more favor- able outcome. The majority of the elderly who need GCM ser- vices have families who live out of town.
Why Do APNs Make Great Care Managers?
• APNs generally have better access to physicians and other health care providers, and are able to coordinate services for their patients.
• APNs perform comprehensive assessments (and physicals), treat and admit patients to health facilities (when necessary), and order and closely manage medications.
• APNs, as health care experts, assist their patients in navigating acute and long-term care systems more efficiently and easily.
What Services Can APN-GCMs Provide?
Patient care management
After an elderly patient or family caregiver contracts with an APN- GCM, the APN will assess what the patient's health and long-term care needs are, coordinate and manage the services that appropriately meet those needs, provide an ongoing assessment of the client's health care status and needs, and intervene in a crisis when the patient's health con- dition suddenly changes. The process usually follows these steps:
1. The patient and family caregiver together sign a service contract that stipulates what services will be rendered to the patient.
2. The APN visits the patient and conducts an assessment (usually a focused assessment).
3. A problem list is formulated and prioritized.
4. From the problem list, a care plan is developed and discussed with the elderly patient and his or her family.
5. When necessary, referrals to other licensed personal care and homemaker services are made and coordinated by the APN-GCM
20 MANAGING YOUR PRACTICE
(unless the elderly patient or family member wants to contract these services separately).
6. The APN-GCM acts as a private consultant, available 24 hours a day, 7 days a week, managing all the patient's health and long- term care needs.
7. The APN-GCM maintains communication as long as it is needed with the appropriate providers, including the primary care physi- cian and other health care agencies.
Ongoing care management services
Ongoing care management for frail elderly, disabled, and chronically ill patients who prefer to stay in their own homes, includes the following:
• Weekly, bimonthly, or monthly home visits that assess a patient's health (e.g., diagnosing and treating minor illnesses and medica- tion management) and personal care needs.
• Ongoing assessments and care plan revisions.
• Daily, weekly, or monthly telephone consultations with the elderly and/or family members to address ongoing health care issues.
• With the patient's approval, telephone updates are made with all health and long-term care providers involved in providing care for the elderly patient.
• Advice on where to purchase needed health care products and medications at the lowest cost.
Steps for Developing an APN-GCM Practice
Step I: The practice plan
• Determine the structure of the practice (e.g., sole proprietorship, S corporation, limited partnership, or other).
• Establish a timeline for the practice.
• Develop marketing strategies.
• Arrange coverage for the APN's vacation or illness ahead of time.
• Outline a plan for securing capital.
NEW PRACTICE MODELS FOR APNS: THINKING OUTSIDE THE BOX 21
Step 2: Marketing
• Develop a brochure that clearly stipulates the type of services being offered, the credentials of the service provider (e.g., your APN resume), and scenarios for ways in which the service is used by the patient (e.g., the long-term care of a patient trying to cope with a cancer diagnosis).
• Determine the mailing list. For example, the brochure can be mailed with a cover letter to home health and hospice agencies, hospitals, nursing home and rehabilitation center discharge plan- ners, physicians, parish nurses, senior service organizations, community senior services agencies, insurance companies, bank trust departments, and elder law attorneys.
Step 3: Legal issues
• Maintain your APN license.
• Obtain proper care management certifications (e.g., Certified Case Manager [CCM], Certified Managed Care Nurse [CMC], Certified Disability Management Specialist [CDMS], and/or Cer- tified Rehabilitation Nurse [CRC]).
• Review your state's scope of practice for APNs.
• Secure a professional liability insurance policy to cover APN ser- vices, care management services, and general business liability.
• Review all contracts and legal forms with legal counsel for proper compliance with practice laws.
• Develop patient files, and include signed contracts, release forms, and accurate, current, and meticulous progress notes.
Step 4: Billing issues
• Establish a billing process using accounting software that pro- vides the capability to maintain proper patient and business finan- cial information.
• Do monthly billing to the elderly patient, family caregiver, third- party payer, trust department, or long-term care insurer.
• Invoice services rendered on behalf of patients, based on the ser- vice contract, which include, but are not limited to, telephone
22 MANAGING YOUR PRACTICE
time, travel time, and home visits. For accounting purposes, this should be recorded in 10- or 15-minute increments. Current rates vary nationally, but most nurse case management charges range from between $70 an hour to $125 an hour.
• Become familiar with and follow standard accounting practices.
• Secure the advice of a tax accountant.
• Conduct business audits every 2 to 3 years.
Is Help Available?
Online help for geriatric care managers can be found on the National Association of Professional Geriatric Care Managers' Web site at www.caremanager.org.
Is This a Viable Practice Model for APNs?
Each day nearly 6,000 Americans turn 65 years old. In 10 years, that number will increase to 10,000 Americans each day. As the baby boom becomes the "senior boom," the need for APN-GCMs will explode.
Based on patient requirements, an APN-GCM can handle from 5 to 10 patients simultaneously, billing $1,000 to $3,000 per month. Depend- ing on the practice model, it may take a few years to develop a sub- stantial patient base; however, many APN-GCMs subcontract their services to hospitals, physician practices, long-term care providers (e.g., rehabilitation and skilled nursing facilities), home health care agencies, and outpatient clinics to supplement their practices.