To illustrate the inequity in funding staff at the Good Samaritan Care Center, Jay Ophoven, director of nursing, whips out sheets of daily reimbursements. The daily rates at the Good Samaritan are $10-$25 less than nursing homes in the cities.What really strikes Ophoven as unfair is when he looks at a recent bill from a downtown Minneapolis hotel, which charges almost twice the Good Sam's daily rate for a one-night stay.
The hotel costs $140 per night, but the Good Samaritan can charge only $78.46 as its lowest rate for total care. That includes meals, medicine, nursing care, and everything else the resident needs. The hotel provides a bed, clean sheets and towels, and charges for meals and extra items.
"That's my main problem," said Ophoven. "If I got paid more, I could pay my staff more. They work hard. They deserve it."
Sue Brink - a nurse's assistant and certified medication assistant - gives medicine to Good Samaritan resident Donna Luskey.
Local nursing homes get paid less than others because of a state system that classifies those in the Twin Cities as urban, those in St. Cloud as rural, and those in Paynesville as deep rural.
That might have been appropriate 30 years ago, when people only worked close to home, and wage differences in these regions were offset by the cheaper cost of living. But in the mobile society of today, commuting allows people to look for higher wages a little farther from home. "I'm competing with these facilities that can pay their people more," said Ophoven.
As for the hotel, Ophoven notes the difference between what the free market charges and what their facility gets.
Ophoven used to work in a 340-bed facility in the cities, so he knows that the staff here is more caring and compassionate than their higher-paid peers. "A lot of the staff here have family here," he explained. "They not only treat them like family; they are family."
"With that dedication and loyalty, I should be able to pay them the same as the cities," he continued.
The only nurses he can pay more are the pool nurses that he sometimes needs to cover a shift. The staff tries to cover for each other, and Ophoven prefers to pay his own staff overtime. In a pinch, though, he has to hire from a pool, at several times the regular hourly rate.
Nursing homes provide care around the clock. They can't just close early when they are short of staff. And sick staff can't just suck it up and come to work; they are encouraged to stay home to prevent spreading their illness.
Paperwork
Should you step into a health care administrator's office and ask about paperwork, be prepared to have a series of three-ring binders shoved past your nose.
"This is one of our rule books," said Good Samaritan administrator Tom Kooiman with a sigh, holding a three- or four-inch binder in the air.
"There are rules for rules," he added. "With each regulation they add," said Bev Mueller, patient care administrator at Paynesville Area Health Care System, "there's more paperwork."
Willie LaCroix, administrator at PAHCS, goes as far as saying that computers haven't saved time at all, at least not in nursing. With the priority on documentation, it takes nurses from the bedside and puts them in front of a computer.
Karen Ampe, nursing supervisor at Koronis Manor, is one of the two nurses in the system who spends her days doing paperwork, and then takes more home at night. Ampe has two secretaries to do all the paperwork they can, but the charting and patient summaries have to be done by a qualified nurse.
"It's a massive, complicated form," she said of the federal paperwork. "It's so open for interpretation, and this is what our reimbursement is based on and our survey," she added.
Missing items means missing reim- bursement. "You had it in the chart but you didn't put it in the summary. It's like you didn't dot an i or cross a t," she said. The theory behind paying for the documented care sounds fine, Ampe said, but the trend now is to pick holes in the chart regardless of the result.
Ampe recalled one case where the Koronis Manor staff took great care in changing dressings, applying antibiotics, and caring for a patient with an infection. "We kept her stable, we had a good outcome, and the patient went home," she said.
Only they didn't get reimbursed for most of their care because the patient was ruled as unstable, which was the outcome their care was intended to prevent, according to Ampe. "They could obviously see from our documentation the hours of care we provided. Why weren't we reimbursed for that?" she wondered.
Charting used to be done by exception, where you only noted the changes and unusual things. Now, said Ophoven, "If you didn't document it, it wasn't done. That's their take on it. So it's write, write, write."
PAHCS documents "everything we do," said LaCroix. "Even if it takes two nurses to do it, because you can't afford not to."
Aging work force
America is growing older, and so are its nurses. The labor pool is tightening, and the crunch in nursing could get worse when current nurses start to retire.
According to Ampe, the average age of working registered nurses is 45. "we've got to get some young blood in the profession," she said.
Of critical importance is keeping employees and allowing them to advance in their profession. Both the Good Samaritan Care Center and PAHCS have programs to help employees go back to school. This allows nursing assistants to become Licensed Professional Nurses or Registered Nurses.
Enticements - like moving expenses, signing bonuses, and debt forgiveness - are growing in the industry. The situation has similarities to the recruitment of physicians a decade ago, when inducements were started to attract them to rural areas.
Ampe said being creative in scheduling and marketing well would be key to ample staffing. The demands of keeping the facility open for 24 hours per day might lead them to hire people for shorter shifts, especially at high demand times like morning (getting out of bed and eating breakfast) and the evening (eating dinner and getting back to bed.) Someone might not be able to work a complete day shift but could work flexible hours.
With employees in demand, Ampe said, "they're going to go find a job that works right into their needs."
"If we don't market ourselves, they're going to get a job somewhere else," she added.