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“Case 12: The Visiting Nurse Association of Cleveland”

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    Case Review and Analysis

    “Case 12: The Visiting Nurse Association of Cleveland”

    There must always be a delicate balance between the needs of clients and the needs of business. In times of change, this is even more true. It takes a progressive, forward-looking health care company to adapt to changing economic situations and changing patient needs while still remaining viable as an organization.

    In Case 12 “The Visiting Nurse Association of Cleveland, such a company must make vital decisions about its future direction. These decisions, and the way in which they are made, will have an effect on thousands of clients and employees. This case illustrates how important effective planning is in the process of maintaining a growing and responsive health care entity.

    Mary Lou Stricklin, the Chief Executive Officer of the VNA will have many challenges in charting the future course for the organization. She will be pressured by many people to move in many different directions. To assure the future of the VNA she may need to resist the pull of conventional wisdom. During this treacherous economic period the organization may need to put expansion on the back burner in favor of an inward focus on quality control. When both consumers and governments are less cash-strapped, the organization will be prepared to resume aggressive expansion.

    Case Background

    The Visiting Nurse Association of Cleveland (VNA) is a large provider of home health care services in Cleveland, Ohio and its surrounding area. It serves a local population of over one million people. The VNA was able to expand both its services and the number of clients served in the 1980s and 1990s due to several factors.

    The establishment and subsequent expansion of federal assistance programs like Medicare and Medicaid has allowed for greater services for home bound patients or other patients needing in-home medical services. Cleveland charities also enjoy an above average rate of giving from the community. Some of these funds are available for home care services.

    The Mission Statement of the VNA sets forth an ambitious vision for company growth and excellence. Key ideas within the statement include compassion, innovation and dignity. The company has a vision to be no less than the best in its field, a leader in both patient care and research. It seeks to be responsive to both the community and company stakeholders while continually advancing the skill level of its employees and the people they serve.

    Charting a course

    The VNA has served the greater Cleveland area for over a hundred years. In the 1960s, the VNA began to expand due to the creation of “Great Society” programs like Medicare and Medicaid.

    In the 80s the VNA implemented an organizational structure with nurses in the positions of decision-makers. This applied not only to health issues but also to the financial viability of its clients. In fact, “The nurses themselves decided whether or not a patient was able to pay” (288). Tougher means testing by Medicare and other organizations modified this practice.

    Many of the clients who were referred to the VNA were done so by hospitals. In time this would spur the growth of the VNA itself. According to Duncan Neuhauser; “Hospitals wanted full-service agencies” (290). In the 1980s the VNA faced competition from many start-up firms.

    The lack of tight regulations and oversight at the time made it easy for many tiny home health care operations to clutter the market. Over 300 firms entered the home care market, including hospital-based firms. Some of these firms were acquiring clients by ethically questionable means. The VNA’s survival during this unregulated period was in question. In order to succeed during this time the VNA had to become fully credentialed, provide a wide array of services and establish a reputation for quality service. It decided to focus on quality of service rather its less ethical competitors.

    The VNA also streamlined its intake process during this period. It identified the most frequent sources of their referrals, and then stationed liaison personnel at these locations. The liaisons worked with the hospitals, as well as providing a modest amount of promotion for the VNA, such as posters, signs and pamphlets.

    At VNA headquarters a centralized referral service with one phone number was developed. All referrals were taken at the Cleveland office, and then assigned to nurses in the field. The foray of hospitals into the home care services field began to wane in the mid-1980s. At the same time, the relationships the VNA had developed with the hospitals began to pay dividends.

    In the 1990s the VNA divided itself into several different service categories, including a for-profit division. Meanwhile, the trustees were reduced to a fewer number of individuals. A board of overseers was formed monitor the actions of the organization but has no direct authority over it. The organization profited enough to build a new headquarters.

    The VNA has been able to provide a wide variety of services to the community. In recent years it has targeted its efforts toward more underserved special populations.

    “Special populations served included alcoholism, mental health, AIDS, bereaved families and the elderly living in low-income housing” (292).

                The range of services now offered is impressive. Pediatric and maternal services are provided through several of the VNA’s programs. Rehabilitation services, including physical and occupational therapy, are also popular services. The VNA also offers in home treatments, such as infusion therapy, chemotherapy and others, relieving the patient from the need to make frequent hospital visits for these therapies. The VNA has also increased its offerings in behavioral health, having instituted several mental health and chemical dependency programs.

                The VNA hospice is a special division of the association. It provides round-the-clock, comprehensive in-home care program for patients not wishing to enter a nursing home or permanent care facility. The program is constructed from an interdisciplinary perspective, including medical professionals, clergy, mental health and social work professionals.

    Analysis and Conclusion

    In an organization as wide-ranging at the VNA, a continual focus on ethical training is critical. This process has to be efficient as well. Neuhauser notes that “Fraud and abuse rules mean that unintentional reporting errors can lead to an expensive government review and penalties” (294).

    Expanding VNA’s reach to additional neighboring areas poses difficulties. Finding qualified nurses in rural areas, or willing to work there, will be difficult. Establishment of localized training programs that give the nurses incentives to work in these areas would have to precede full-scale operations in these areas.

    The largest single payer into the VNA is the federal government, through its Medicare and Medicaid program. The economy is being squeezed and, most likely, so will these programs. Companies such as the VNA are under increasing pressure to justify spending. Doing so will entail a renewed effort at streamlining the care process and operating the organization with maximum efficiency. Forming a research center to find better ways of doing this can help ensure the best possible funding level from the government. The center could also seek out new funding sources as well as capitalize more on the current sources.

    The economy is, arguably, in a recession. This makes expansion plans more difficult. The organization’s work force could easily be stretched too thin for an aggressive expansion. The corporate structure is prepared for such an expansion, but not the organization as a whole. The current lack of qualified and vested nurses in the organization could lead to a drop in service quality for clients. That drop in quality, in turn, could endanger federal funding as well as private contributions.

    A temporary internal refocusing of the organization may not be agreeable for some stakeholders, but it is necessary for long-term stability. Upper-level managers like Ms. Stricklin are likely to feel pressure from a number of angles. Implementing new quality control measures can be unpopular with the rank-and-file if not done carefully. Such measures can also become bogged down by inefficiency if not implemented in a well-planned, corporate mentality.

    Morale is important in any organization. If people feel that the forward momentum of the organization is stalled they may begin to feel insecure about their own prospects. Whatever course is chosen by the VNA, the best method for maintaining morale is to solicit and act upon employee input in a systematic manner. This is not only important for the employees; it is important for the organization as a whole. Top-down planning often leaves out the vital information rank-and-file employees can provide.

    A systematic effort to include employees in the planning process increases their “buy-in” to that process.

    Now is the time for the VNA to pare down waste and minimize mismanagement. Doing so will position the organization for effective service-oriented expansion in the future. Expanding already established services, such as the VNA hospice, can help bring new clients and funding into the organization. In the longer term, the prospects for expansion look good. Healthcare is America’s largest industry and promises to remain so for the foreseeable future. Fig. 1 shows a suggested assignment of priorities.

    Currently the demand for nurses outstrips the supply. A large number of nurses are nearing retirement age and not enough young nurses are replacing them to meet demand. This shortfall will require innovative solutions by companies such as the VNA. There are many ways to draw more new nurses into the field.

    Fig. 1 Proposed areas of focus

    Short Term   < 10 yrs.                                       Long Term    10 yrs. +

    Ø  Incentive and retraining programs                ►  Expansion to underserved areas

    Ø  Strengthen ties w/local nursing                     ►  Hospice expansion

    schools                                                           ►  Political advocacy

    Ø  Strengthen ethical and occupational             ►  Grow for-profit division

    training programs                                          ►  Widen donor base

    Ø  Research center                                             ►  Develop comprehensive

    Ø  Enhance services within local area                            contingency plans

    The most obvious recruitment tool is to increase compensation. The VNA can do this only to a certain extent limited funding will allow. In its particular areas of service it is difficult for the VNA to compete on salary and benefits with large, suburban hospitals. There are other ways to compete however, For example, flexible scheduling options are popular with many employees.

    Meanwhile, a continued upward trend in demand for services is expected to occur. Advances in medical technology and treatment promise to extend life spans for many years. That, in turn, will create more demand for long-term home health care and hospice service. The prospect of a nationalized or a public/private hybrid health system could also increase demand. Meanwhile, HMOs and other insurance concerns are limiting in-patient stays and services. As a result an increasing proportion of care could fall to the home health care system.

    The American population is aging and the Cleveland area is no exception. The need for more beds at the VNA’s hospice center is almost assured.

    Health systems and individual group practices are likely to become more complicated in the coming years. This is further justification for implementation of a research center to assist with funding issues.

    Encouraging the Board of Trustees to support these steps is critical to successful implementation. The Board is comprised of members with a wide variety of backgrounds and personal concerns. A concerted effort to address these individual concerns will require a focused effort from VNA management.

    Part of this process should involve creating links between the Board of Directors and the front line staff. Formal and informal meetings can help form a mutual understanding of what needs to be done and how best to go about it. Along those lines, taking Board members on site visits to the hospice and other VNA service sites can give the members a perspective beyond what they see on formal company documents. Staff input should also be presented to the Board as part of the decision making process. This has a two-fold purpose. First, it gives the board a clearer idea of what is going on within the organization and more possible options for addressing organizational issues. Secondly, it empowers the employees of the organization. Instead of feeling helpless in an organization that is changing around them, they now feel a part of creating effective change that will provide future security.

    Mary Lou Stricklin is uniquely qualified to meet these challenges. She is a nurse in addition to having her Masters degree in Business Administration. The VNA Mission Statement contains a section on Values that will be particularly important to the organization as it grows. Stricklin understands the pressures, often financial, that can cause an organization to stray from its core principles.

    The future is bright for the Visiting Nurse Association of Cleveland. Demographic and social factors favor future growth of the organization. The near-term forecast is trickier, though. Overexpansion in the current economic climate could be dangerous for the future health of the VNA. At the same time, the current environment provides an opportunity to refocus on internal matters such as quality control and acquisition of additional funding sources.

    Source

    Kovner, A. and Neuhauser, D. (2004). Health Services Management: Readings, Cases

    and Commentary (8th ed.). Chicago: Health Administration Press.

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    “Case 12: The Visiting Nurse Association of Cleveland”. (2016, Jun 22). Retrieved from https://graduateway.com/case-12-the-visiting-nurse-association-of-cleveland/

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