Comparing in-person, video, and telephonic medical interpretation.

BACKGROUND: Using trained interpreters to provide medical interpretation services is superior to services provided on an ad hoc basis, but little is known about the effectiveness of providing their services remotely, especially using video. OBJECTIVE: To compare remote medical interpretation services by trained interpreters via telephone and videoconference to those provided in-person. DESIGN: Quasi-randomized control study. PARTICIPANTS: Two hundred and forty-one Spanish speaking patient volunteers, twenty-four health providers, and seven interpreters. APPROACH: Patients, providers and interpreters each independently completed scales evaluating the quality of clinical encounters and, optionally, made free text comments. Interviews were conducted with 23 of the providers, the seven interpreters, and a subset of 30 patients. Time data were collected. RESULTS: Encounters with in-person interpretation were rated significantly higher by providers and interpreters, while patients rated all methods the same. There were no significant differences in provider and interpreter ratings of remote methods. Provider and interpreter comments on scales and interview data support the higher in-person ratings, but they also showed a distinct preference for video over the phone. Phone interviews were significantly shorter than in-person. DISCUSSION: Patients rated interpretation services highly no matter how they were provided but experienced only the method employed at the time of the encounter. Providers and interpreters were exposed to all three methods, were more critical of remote methods, and preferred videoconferencing to the telephone as a remote method. The significantly shorter phone interviews raise questions about the prospects of miscommunication in telephonic interpretation, given the absence of a visual channel, but other factors might have affected time results. Since the patient population studied was Hispanic and predominantly female care must be taken in generalizing these results to other populations.

Estimating nursing intensity and direct cost using the nurse-patient assignment.

BACKGROUND: This study examines the feasibility of using the nurse-patient assignment (NPA) to calculate direct nursing hours and costs for each inpatient-day. The NPA data are collected at every hospital and therefore represent a readily available information source that can establish the intensity and economic value of nursing care at US hospitals. METHOD: Direct nursing care hours for each patient were collected twice a day using an existing nursing intensity database at a single university hospital between January 2004 and June 2005 for a total of 11,582 patient-days. Nursing intensity was also calculated for each shift using the NPA. Mean unit and hospital nursing hours were calculated and compared with the direct nursing care hours using ordinary least squares regression. RESULTS: For the day shift, the NPA estimate explained 77.2% (r2 = 0.772) of the variance of patient-level nursing intensity. Unit and hospital mean estimates of nursing intensity had lower r of 0.574 and 0.456, respectively. The night-shift NPA, unit, and hospital r2 estimates were 0.824, 0.633, and 0.579, respectively. CONCLUSION: The use of the NPA can provide a robust and easy method to calculate nursing intensity for individual patients using assignment data available in nearly all care settings. The NPA estimate can be used to allocate direct nursing time and costs for each patient within the hospital billing system and can also be used in pay-for-performance or for benchmarking nursing intensity within and across hospitals.

Nursing intensity: In the footsteps of John Thompson.

The Nursing Minimum Data Set (NMDS) provides a way to incorporate nursing data into the hospital discharge abstract to potentially compare nursing care across institutions. An extension of this framework is to use these data for directly billing and reimbursing hospital nursing care. We provide a review of the existing literature and new empirical evidence to support hospital nurse billing. Two existing large data sets are compared, one using nursing diagnosis and the other a nursing intensity based tool to collect daily nursing times. These NMDS data sources are compared to diagnostic related groups (DRG) and hospital outcomes from the UB92 discharge abstract using multivariate regression and logistic regression. Either NMDS approach provides additional explanatory power (improvements in R2) over DRG alone. The findings strengthen the argument to use primary nursing data such as nursing intensity as a basis for direct costing, billing, and reimbursement of hospital nursing care.

Hospital nursing costs, billing, and reimbursement.

Nursing intensity, estimated direct nursing costs, and daily billing were compared for 12 adult medical or surgical units at an academic medical center from January 1 to May 31, 2005 (22,649 patient days). Two main findings, nursing intensity and direct nursing costs, were highly variable within and across each of the study nursing units (mean 429 dollars, SD 160 dollars); direct costs of nursing care were significantly higher for private room rates compared to intermediate room per diem charges billed at a higher rate (441 dollars vs. 426 dollars, F 37.77, p < 0.001). The results demonstrate that the direct costs of nursing care are not aligned with current billing practices at this university hospital. The use of fixed room and board charges to account for nursing care in U.S. hospitals may be obsolete and an alternative nurse-centric costing, billing, and reimbursement model is proposed.

Nursing intensity billing.

UNLABELLED: Hospital nursing care has traditionally been billed using a fixed daily room and board rate. This approach hides the variability of nursing care within and across nursing units and does not align nursing costs with daily charges for actual patient care. Anew nursing intensity billing (NIB) model for assigning hospital daily room charges is proposed, and initial results are reported. METHODS: Two charge methods, one using traditional room and board daily billing and another using an NIB approach, were developed for 12 adult medical or surgical units at the Medical University of South Carolina (MUSC) Medical Center using retrospective data from January 1 to May 31, 2005. The room and board charge was assigned as private room or intermediate care based primarily on patient location. The NIB model added an additional focused care charge between private and intermediate care, and the charge for the 3 levels was based on daily nursing intensity entered as actual hours of nursing care delivered. The mean and sum of charges were compared between the 2 methods. Charge rates were simulated at $700, $950, and $1,200 for the 3 levels, which correlated with the existing proprietary room rates. Nursing cost-to-charge ratios were calculated for room and board and NIB methods. RESULTS: The NIB model resulted in a 32.2% increase in charges or a total sum of $4,870,250 for the 12 nursing units over the 5-month period. The variability of nursing cost-to-charge ratio was reduced from 0.34 to 0.80 for room and board to 0.33 to 0.45 for the NIB method. CONCLUSION: The NIB method of assigning charges based on nursing intensity rather than on patient location increased overall charges and more evenly distributed direct nursing costs to daily charges. Assigning charges based on nursing intensity is appealing as it reflects actual care given in the acute care environment. The NIB provides evidence to support higher charge rates and has the ability to redistribute hospital charges based on nursing care. The relationship between increased daily hospital charges and actual reimbursement is unknown.

Adjustment of inpatient care reimbursement for nursing intensity.

The Centers for Medicare and Medicaid Services has begun an ambitious recalibration of the inpatient prospective payment system, the first since its introduction in 1983. Unfortunately, inpatient nursing care has been overlooked in the new payment system and continues to be treated as a fixed cost and billed at a set per-diem "room and board" fee despite the known variability of nursing intensity across different care settings and diagnoses. This article outlines the historical influences regarding costing, billing, and reimbursement of inpatient nursing care and provides contemporary evidence about the variability of nursing intensity and costs at acute care hospitals in the United States. A remedy is proposed to overcome the existing limitations of the Inpatient Prospective Payment System by creating a new nursing cost center and nursing intensity adjustment by DRG for each routine-and intensive-care day of stay to allow independent costing, billing, and reimbursement of inpatient nursing care.

Organizational commitment to professional practice models.

Magnet hospitals must show evidence of professional practice models. A professional practice organizational environment is necessary, but not sufficient, to create professional practice models. The authors analyze the relationship between a professional practice environment and a professional practice and explore organizational commitments required to ensure professional practice at the unit level.