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Delegating Tasks Can Benefit Home Care Nurses, Health Aides and Patients

New rules would let nurses train home-health aides in variety of tasks, letting each group focus on doing what it does best

susan reinhard AARP
Susan Reinhard of the AARP talks about the benefits of delegating some nursing duties to trained home healthcare aides.

The state and federal governments are making it easier for New Jerseyans to stay in their homes as they age and their healthcare needs increase.

But this shift to home-based care demands more from the nurses who assess and develop plans to meet residents’ needs. It also places increasing reliance on the home health aides who help people in their daily lives.

That’s why a proposed set of rule changes that would increase the range of activities that nurses can delegate to those aides is important. The proposals allow nurses to focus more on the specialized tasks they’re trained to do, while allowing health aides to deliver a wider range of services, like helping clients with their medications.

Making the changes work will require a change in mindset for nurses, health aides, and family members who provide care, but national experts point to evidence that it will enable each group to focus on what it can do best, raising the overall quality and lowering the cost of the care that residents receive.

Susan Reinhard, AARP vice president and director of the organization’s Public Policy Institute, said the obstacles to delegating nursing duties can seem nonsensical to consumers.

“They do not see changing a colostomy or a tube feeding as a nursing task, they see it as an activity of daily living,” and exactly the sort of thing home health aides should be able to help with, Reinhard said.

The rule change would allow health aides to do any task that is within a nurse’s scope of practice and that can be done with little risk to patients and without the need for nursing judgment, as long as the nurse can teach the aide how to do it and is comfortable that the aide is competent to do it. The focus is on patients with chronic conditions receiving long-term care, and includes giving medications orally or through injections, and helping with eye drops, catheters, and enemas.

“It would really help people stay at home, where they would prefer to be, and receive really good care from nurses’ aides, who are supervised very carefully and closely by registered professional nurses,” she said.

New Jersey already allows nurses to delegate some tasks to health aides, including administering a feeding tube, but many nurses aren’t aware of this, according to experts familiar with the issue. And while nurses have been able to delegate a full range of tasks to patients’ families, these relatives often find it difficult to be available to help. For example, family members may have to make a trip home during lunch to give a relative medicine, but the need for the trip could be eliminated if the home health aide was able to take care of the task.

That’s part of the reason why one of the most forceful advocates for the rule change is AARP New Jersey, which has been pushing for steps to assist family members who serve as caregivers to loved ones.

These folks “often find themselves home alone without the ability to have a home health aide, who is trained to help them with the administration of medication that their loved ones need,” said Evelyn Liebman, AARP New Jersey associate state director for advocacy.

AARP New Jersey officials gathered a wide range of stakeholders last Friday at its Plainsboro headquarters to discuss the proposed rule change and its future implementation.

Reinhard, the former codirector of the Rutgers Center for State Health Policy, pointed out a major reason why the rule change makes sense: Many health aides are already doing these tasks -- illegally. That’s because health aides often find themselves alone with the patient when no one else is available.

New Jersey currently ranks roughly 30th among states in the amount of tasks that nurses can delegate, but the rule change would make it one of only 10 that doesn't limit delegation to a specified list.

The state tried a pilot program from 2008 to 2011, in which 19 home health agencies focused on expanding the tasks that nurses delegated. The results were positive, with consumers, family caregivers, home health aides, and nurses all reporting positive experiences. The costs were only $550 per person annually, which Reinhard noted was slightly less than what four days in a nursing home costs the government Medicaid program, which pays for much of the nursing care in the state.

But, Reinhard said, “there’s a real disconnect in New Jersey,” between the authority that nurses already have to delegate tasks and their knowledge that they can do so. She said the rule change offers an opportunity for the nursing industry to benefit from delegation.

Deputy Human Services Commissioner Lowell Arye said the lack of delegation has contributed to some residents moving to nursing homes, since the costs for home-based care can become “astronomical.”

“That’s not what anyone wants to do,” Arye said of people moving to nursing homes when they don’t have to.

Dr. Poonam Alaigh, who leads post-acute-care strategy for Atlantic Health System and is a former state health commissioner, said she has found that a leading reason why long-term care patients make trips to hospital emergency departments is the mismanagement of medication.

By outlining home health aides’ ability give medications, the rule change has the potential to improve patient care, Alaigh said. She also noted that it could help in the health system’s move toward allowing providers to “practice to the top of their license.” That’s the concept that healthcare works most efficiently when each provider is doing the tasks that require their specialized training, and not tasks that could be done at lower cost by others.

Officials with the Home Care Association of New Jersey, a trade group for home health agencies, said they see benefits to expanding delegation, noting that it will become more effective as nurses become more comfortable with it.

“It really depends on the nurses’ level of judgment, and the caregiver -- whether that’s a family member or an aide -- their comfort level and your ability as a nurse to instruct, educate them, and be assured that they can carry out whatever the task is,” said Karen McCoy, who directs professional development for the association.

Public comments on the rule change are due on April 3.

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