Ellen Leff, RN, Director of Clinical Services for Franklin County Home Health Agency, was named "Nurse of the Year" by the Vermont State Nurses' Association at their annual convention held on October 26, 2000 at the Capital Plaza Hotel in Montpelier.

According to Sandy Floersheim, a member of the VSNA Board of Directors, Leff was selected as VSNA Nurse of the Year based on several criteria including: education, nursing experience, community service, VSNA activity, other state or national offices held, awards or honors, and publication of articles.

In her presentation of the award, Floersheim characterized Leff as "a gifted nurse, highly capable community leader and wonderful person who exemplifies humility, honesty, and intellectual integrity."

"No other nurse," according to Floersheim, "has contributed to the scientific basis for practice to the degree that she has. She has made evidence based practice the norm wherever she worked."

"I can't think of any better way to acknowledge the contributions that she has made to the profession of nursing, than to recognize her as Nurse of the Year," said Floersheim.

"I was surprised and honored by this award," says Leff. "In my position at Franklin County Home Health, I've had an opportunity to practice in all of the professional nursing roles: clinical, administration, teaching and research. It's nice to work in a small agency where there's good team work
and accessibility to each other-it's more like a family feeling." Leff has worked at Franklin County Home Health Agency since 1995 as the Director of Clinical Services. There, she is responsible for coordinating the patient care activities for the Agency, including service delivery, policy and procedure development and implementation, staff development, and performance improvement. Her leadership has contributed to the Agency's successful accreditation with commendation from the Joint Commission on Accreditation of Healthcare Organizations.

Leff is also an Adjunct Assistant Professor of the University of Vermont's School of Nursing and the President of the Champlain Valley Area Health Education Center Board of Directors, which have allowed her to combine her passion for education with the profession of nursing. She often serves as a preceptor and mentor for undergraduate and graduate nursing students. According to Leff, "I'd really like to encourage young people to think about careers in nursing. There are so many opportunities in nursing be in a caring profession using whatever interests and abilities they may have."

Janet McCarthy, Executive Director of Franklin County Home Health Agency, considers Leff an excellent choice for the award. "Ellen promotes a positive image of nursing at all times," said McCarthy. "Not only is Ellen a strong advocate for excellence in nursing practice, she models it every
day. Her energy and commitment to the profession of nursing is tireless, and Ellen is an outstanding choice for VSNA Nurse of the Year."

Virginia Fry, Executive Director of the Hospice Council of Vermont, is one of two editors of a special November 15 edition of Patient Care: The Practical Journal for Primary Care Physicians. This issue of the journal has articles on advanced directives, palliative care options, hospice programs, life-prolonging technology, and ethical case studies. The co-editor is Karl Singer, MD a family physician and general internist in Exeter, New Hampshire and the Medical Director of Patient Care Journal.

"When I was asked to be a Medical editor for a special issue of Patient Care that would focus on end-of-life care, my first response was a question. "Do you realize that I am NOT a doctor? I’m an artist and a counselor and I occasionally teach medical students and doctors," Fry writes in a guest editorial.

"The editors did indeed know I wasn’t a physician. They said that experience in hospice work over the last 20 years was what was needed - that along with my efforts to bring creativity and compassion into the medical realm of death and dying prompted their offer. I agreed."

In addition to helping edit the November 15 edition, Ms. Fry also is a contributor with Robert Buckman, MD and Ira Byock, MD on an article entitled: "Talking with patients and families." This article details the fact that training and experience are needed to effectively share bad news, elicit feelings and preferences, and discuss difficult issues.

"The key to quality end-of-life care is a trusting physician-patient relationship and satisfying communication." Fry said.

Also, Ms. Fry’s illustration of a fable from India about seizing the moment is featured on the front cover of the magazine.

"I’ve drawn a famous story from India, using traditional images from ancient Asian art. I give it to may patients, family members, and all the professional caregivers I can reach. It definitely is not an American story. But it does have universal meaning for all. The Buddhist meaning is that as long as we are human beings, we are stuck between birth and death," Fry said.

The story is about a woman caught between two tigers and is clinging to a vine that is being destroyed by a mouse. Faced with a desperate situation she sees a strawberry and plucks it and pops it in to her mouth. Her last word is "sweet".

"The only way to cope with a situation like this is to reach out and eat the strawberry and take the joy that is available each day."

Despite the dramatic decline in revenues, Vermont agencies have continued to serve all Vermonters in need. Vermont, in fact, is the only state in the country where no home care agencies have closed since Medicare changed its payment scheme in 1997. Nationwide more than 3,000 of 10,000 agencies have closed over the past three years but none in Vermont.

The VAHHA data mirrors data collected from several other sources, including the Health Care Financing Administration. According to data from the HCFA Region 1 office, Medicare payments to New England home care agencies were $631,329,272 from April 1998 to March 1999, but only $562,891,749 from April 1999 to March 2000. In Vermont, according to HCFA, Medicare payments dropped from $27,845,222 to 26,466,698 for the same time period.

Starting October 1, 2000, home care agencies in Vermont and nationwide entered a new world of Medicare payments, the Prospective Payment System (PPS). PPS is the third Medicare payment scheme in the past three years for home care. Not only have agencies had to adjust their businesses for each new system, but also the Interim Payment System, which lasted from October 1, 1997 until this year, cost Vermont agencies millions of dollars in lost revenues.

To help solve the problem of too few nurses in Vermont, the state should create a center for nursing, establish a state-funded Vermont Education Loan Forgiveness Program, create a marketing program about nursing, increase state funding to expand nursing continuing education programs and expand the capacity of current in-state nursing program, according to the Blue Ribbon Nursing Commission. The Commission, established by Jane Kitchel, the Secretary of the Agency of Human Services, was instructed to present solutions to the nursing shortage in Vermont. The final report will be presented to the Vermont Legislature in January. The price tag for the Commission’s wish list is $3,600,000.

"Vermont is experiencing a nursing shortage, which, if not corrected, will erode the quality of health care in Vermont," Mary Welz, author of the report, told an audience of about 120 at the Nursing Summit 2000, sponsored by the Vermont Organization of Nurse Leaders and the Vermont Association of Hospitals and Health Systems.

Part of the problem of too few nurses, according to the report, is the fact that fewer students are entering nursing education programs at the same time as the average age of a Vermont nurse is 45 and climbing. Even worse, the average age of the nursing instructors at Vermont nursing schools is 54.

According to a recent survey by the Vermont Association of Hospitals and Health System, home care and nursing home associations, on June 26, 2000 there were 134.9 full-time equivalent job opening for Registered Nurses, 70.1 Licensed Practical Nurses and 148.3 Licensed Nursing Assistants.

"We can’t change the fact that our workforce is aging" Pamela Thompson, Executive Director of the American Organization of Nurse Executives, told the assembly. What we can change, Thompson said, are the working conditions and payment rates that are not attracting new nurses or keeping current nurses on the job. Better pay and better working conditions are key to solving the problem.

According to the Commission Vermont needs to crate a Center for Nursing in a college or university setting to address ongoing issues of supply, education, practice, and research. The estimated cost is $250,000/year.

The state also should establish a state-funded Nursing Education Loan Forgiveness Program similar to the program for physicians. Under this program the state would help pay the student loans of nurses who agree to practice in Vermont. The cost is estimated at $2 million.

The Commission also proposed a partnership between the State of Vermont, health care providers and educators to fund a comprehensive program to promote the profession of nursing. The estimated cost is $250,000.

The state also should increase state funding to expand nursing continuing education programs. This would keep nurses abreast of changes in health care. The estimated cost is $350,000.

The final recommendation is to expanded the capacity of the current nursing program in the state. "Over the past several years, the number of faculty serving in nurse education programs has been reduced markedly, both as a result of fewer students entering into nursing and because of budget constraints," the report states.

The Commission concluded: "It is important that those who have the power to correct Vermont’s nursing shortage - the Governor, our legislature, health care administrators, health care leaders and health care professionals including nurses - come together as a collaborating and unified force and take action now. The clock is ticking and the quality of health care for all Vermonters is at stake."

Three Franklin County Home Health Agency staff members recently had an article published in The Joint Commission Journal on Quality Improvement. The October 2000 journal contained the article, "Preventing Home Health Nursing Assistant Back and Shoulder Injuries," by Ellen W. Leff, RN, Director of Clinical Services; Gail L. Hagenbach, RPT, Physical Therapist; and Kathryn K. Marn, RPT, Rehabilitation Therapy Clinical Manager.

During a scheduled visit by the Joint Commission on Accreditation of Healthcare Organizations last October, the surveyor reviewed the results of the agency's quality improvement effort on the topic of preventing injuries in nursing assistants. The surveyor was so impressed with the effort, that she suggested the team publish their findings.

"I agreed that this was a project we should be proud of," said Leff. "I thought that it was a good idea to publish our findings as a way to help other health care providers prevent injuries among their nursing assistants."

"Nursing assistants are our most vulnerable population for injuries because of the amount of lifting and transferring of patients that is required by their jobs," said Leff. "Our efforts began in 1996 to improve the amount of injuries in this group by implementing a comprehensive program that includes training and retraining of nursing assistants, intense evaluation of patients and potential hazardous situations, strategic scheduling to limit numbers of heavy-lift patients, and implementation of a screening and training program for new nursing assistants."

The Joint Commission Journal on Quality Improvement is published monthly by the Joint Commission on Accreditation of Healthcare Organizations. Articles submitted for the Journal undergo a rigorous peer review process by experts in the field of quality improvement. The Journal is the only monthly peer-reviewed journal devoted to quality improvement, and is written for quality improvement professionals and other clinical and administrative professionals with interest in or responsibility for quality improvement.

In 1996, Franklin County Home Health Agency realized it had a challenge. The agency’s insurance company identified a high incidence of back and shoulder injuries, primarily among the agency’s LNA's. In the first seven months of 1996, 15 of 22 employee injuries (68%) involved LNA's with a direct cost of $30,338. LNA's accounted for 88% of total cost for workers' compensation. It was obvious that the quality assurance programs in place from the early 1990's weren't getting the job done. In preparation for its first JCAHO survey, the agency adopted a formal Performance Improvement Plan. In September 1996, a multidisciplinary team of two RN's, two PT's and two LNA's was assembled, including a manager of each discipline. The team used a seven step process: determine the current situation, develop a team objective, analysis, potential solutions, results, standardization and future plans.

To define their current situation the team collected specific data about the injuries; e.g., time of day, patient care activity during which injury occurred, use of equipment, length of staff members' employment and severity of injuries.

The team’s objective had three parts: reduce the human costs of injury to both staff and patients, reduce the financial costs of injuries, and eliminate back and shoulder injuries to LNA's. Analysis was accomplished through a brainstorming process that helped the team develop a cause and effect diagram for LNA injuries. The team then used a multivoting process to identify the major risk factors.

This naturally led to devising possible solutions and action plans. The short term solutions (a few months) included providing safety and health training to LNA's and to use risk management forms to identify hazardous situations. Mid-term solutions (6 months) included identifying heavy lift patients and limit the numbers of those patients on LNA daily assignments. Finally, long term solutions (one year) included conducting post-offer, pre-hire screenings of new LNA staff by in-house physical therapists.

The final quarter of 1996 was a busy time of developing and implementing action plans to carry out the identified solutions. By the end of 1996, the agency had:

• reviewed and updated all existing LNA plans of care;

• changed LNA workloads to limit the number and sequence of heavy lifts on daily assignments;

• improved post injury care with the human resources manager collaborating with insurance case managers;

• trained current staff and planned ongoing review and training in body mechanics and safety at annual skills fairs;

• completed the performance improvement plan for all phases of our solutions.

By the end of 1997, the agency had replaced the pre-employment medical exam with a pre-hire questionnaire and in-house post hire screening and training by the physical therapy staff. A life-sized mannequin and weight belts up to 50 pounds were purchased so staff could train at the 50 pound maximum lift required by the job description for LNA's. The team also developed guidelines to determine when a patient lift or transfer is unsafe and included them in the risk management form. The guidelines address factors that could increase the effort to transfer a patient including: a patient's ability to assist, conditions such as spasticity that can interfere, an effort greater than 50 pounds, ability of the family or home caregiver to assist, and the physical layout of the home. Employees are empowered not to perform unsafe tasks but to call their manager for immediate assistance and complete a risk management form as soon as possible. Staff education on these solutions was given over several months.

The action plans were implemented throughout 1998, and by 1999 the team evolved into a safety committee with permanent members.

The results indicate that the agency is on the right track. In 1996 and 1997, there were a total of 39 LNA back and shoulder injuries. In 1998 and 1999, the number of injuries dropped to 19 - a 51% reduction. The safety committee continues to work on standardized screening and prevention processes. Education, training and monitoring injury data are ongoing. The committee wants to evaluate expansion to other staff members.

The agency learned many valuable lessons. Solving complex problems requires commitment, persistence, patience and teamwork. Low cost improvements can be effective if they are feasible and acceptable to staff. Multiple interventions may be necessary and consistent follow-up is critical. Finally, integrating the LNA's into multidisciplinary teams and helping them understand their importance and value may have been the most important effort. If you would like more details about Franklin County's Performance Improvement process, see the October 2000 issue of JCAHO's Journal on Quality Improvement.

The Vermont Development Credit Union is a not-for-profit financial institution that creates wealth and promotes economic development by offering affordable capital and financial services to moderate-income Vermonters. VDCU offers savings programs, financial counseling, personal loans, small business loans, home improvement loans, affordable mortgages, and loans through the Vermont Adaptive Equipment Fund.

The Vermont Assistive Technology Project (VATP) finances and supports programs that increase the availability of information, funding and services to meet the assistive technology needs of Vermonters. The Vermont Adaptive Equipment Revolving Loan Fund is made possible through VATP.

The Vermont Adaptive Equipment Revolving Loan Fund makes loans to Vermonters with disabilities who need assistive equipment. Many not eligible for regular bank loans may quality for adaptive Equipment Fund loans through Vermont Development’s counseling-based lending system. The Adaptive Equipment Fund offers affordable interest rates and reasonable repayment terms. Borrowers must show how the equipment they want to purchase relates to their disability. Since the Fund makes loans, not grants, credit history and current income and expense records are reviewed. Loan terms depend on your ability to repay and the anticipated useful life of the equipment. VDCU can help a client overcome past difficulties and work with you to set up affordable monthly payments. If necessary, VDCU can help find other funding options.

VAERLF loans are offered to any Vermonter with a disability, to family members or legal guardians, and to appropriate nonprofit organizations or partnerships. The loans can be for the full cost of the equipment or for a portion of that cost. Other funding sources will be considered favorably. For example, a client may borrow money through VAERLF for a van and have VR pay for installing a wheelchair lift. Or a person with a learning disability may borrow money for a computer while a local community group pays for additional software and a printer.

Assistive Technology is defined as any device or related service that improves one’s ability to be more independent at home, work, play, or school. The Adaptive Equipment loans help Vermonters buy that assistive equipment, including but not limited to:

• Home equipment and building modifications;
• Work equipment;
• Adapted vehicles;
• Wheelchairs and scooters;
• Hearing and visual aids;
• Computers

For an VAERLF application form, call VDCU: (802) 865-3404 or Toll-Free 1-800-865-8971