MISSOURI
NURSING NEWS
Volume 2 • No. 2
January, February, March 2022
The Official Publication of the Missouri Nurses Association with a quarterly circulation of approximately 72,000 to RNs and LPNs
Message from the President
Caryl Goodyear, PhD, RN,
NEA-BC, CCRN-K, FAAN
As I write this letter we
are experiencing yet another
COVID-19 variant that
may prove to be more of a
challenge. All of us has felt the
stress of the pandemic. We are
concerned about ourselves,
our peers and colleagues,
family and friends. A recent
survey, published in the most
recent American Nurse Journal,
Caryl Goodyear
supported that nurses are feeling stressed, frustrated,
exhausted overwhelmed and anxious.(1) Almost half
of the respondents reported having experienced a
traumatic COVID-19 event and not being emotionally
healthy.
So, what can we do for each other? How can we
show support for others? It is hard to show compassion
to others when we are under stress. However, a good
start is asking the question to our peers, “Are you ok?”
And then to suggest that it’s ok not to be ok. The best
thing we can do for each other right now is to listen.
Listening shows our concern, caring and compassion
for others.
Supporting wellbeing by asking the simple question
is a start to show that we care. Being present with
them is also an important aspect of emotional support.
I would suggest that most nurses would admit that
they get support and wellbeing from other staff. Being
present for each other is vital to everyone’s emotional
wellbeing.
The importance of the simple question of “are
you ok?” signifies caring and compassion for others.
Listening is just a first step to ensure wellbeing is being
addressed.
References
1. Hanley, A. Survey findings reveal nurses are struggling.
American Nurse Journal. 2021. 16(11); 44.
Director’s Letter
If you were to write about
2021 like it was a story, what
would it read it like?
Every year I like to take
time to reflect on the past 12
months while looking toward
the year to come. Reflecting
on the year enables us to
acknowledge and honor what
we’ve been through, what
we’ve learned and how we
can take those lessons into
the new year. This allows us
to process what has happened Heidi Lucas
and move forward.
I reached a big milestone birthday this year and for
most of my life, we have been living in “unprecedented
times.” Wars, terrorist attracts, once in a lifetime
weather events that happen yearly, economic booms
and collapse, political division, and now, a worldwide
pandemic with no end in sight.
But we soldier on. Time waits for no one. The sun
keeps rising. The world keeps spinning. We wake up
every day. We laugh. We cry. People continue to fall in
love. Children keep being born.
Nurses get a front row seat on many of these
life events; peoples best and worst days. And the
pandemic has ratcheted that up to a 1000. It takes a
special kind of person to be a caretaker. It requires a lot
of resilience to keep doing what you are doing. That’s
the beauty of the human spirit and life; the getting
back up, the drive to keep going.
So, keep going.
Stay strong.
Take care of yourself.
Advocate for yourself and others.
Tell us at MONA what you need. How we can help.
Lean on each other. Your colleagues. Your friends.
Your family.
We will get through this.
That’s what my 2021 story would read like. It would
be a story of change, strength, the power of friendship
and family, and hope for the future.
The sun will rise tomorrow. And so will we.
current resident or
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2
Missouri Nursing News January, February, March 2022
Non-Physician Certification in Home
Health Care Blocked by State-Level
Barrier
Existing Missouri law requires orders for home
health services to be written by a physician; however,
many Missourians, particularly those in rural areas,
see an advanced practice registered nurse (APRN) or
physician assistant (PA) for their primary care needs.
For these patients, orders for home health services
must be written by a physician provider regardless of
whether the physician has an existing relationship with
the patient, has not been caring for the patient or has
even met the patient.
This administrative requirement is not necessary
to achieve good clinical outcomes, can disrupt the
continuity of care, and can result in denials or delay of
available care for our seniors.
Thankfully, the ''Coronavirus Aid, Relief, and
Economic Security Act'' or the ''CARES Act,” which
was signed into law on March 27, 2020, permanently
changed federal law so that APRNs and PAs can now
order home health services for their patients. It was a
modernization to the Medicare program!
Now that the federal law changed, it is necessary to
update Missouri’s home health law by simply changing
the definition of home health services to include APRNs
and PAs in the list of providers who may order home
health services for their patients. Sounds easy right?
Unfortunately, the answer is NO! Legislation to update
Missouri’s home health statute was filed during the
2021 Missouri legislative session (will be filed again in
the upcoming 2022 session) and was met with strong
opposition from various physician trade organizations.
While the proposed legislation greatly benefits
Missouri’s seniors, it would not expand the scope of
practice for APNS or PAs and does not impact existing
relationships between physicians and their patients,
however, it seems the decades long “turf war”
continues on in Missouri.
In April of 2020, the state of Missouri implemented
a COVID-19 waiver mirroring the new federal law.
During these past 19 months, thousands of patients,
under the sole care of a nurse practitioner or physician
assistant, have been admitted for home health services.
In a recent survey of home health providers, 90%
responded that the process for ordering and approving
home health services under a APRN or PA was more
efficient and allowed the patient a timely admission.
Data from the care provided during the waiver period
clearly demonstrates that this benefits physician
workload and patient outcomes and satisfaction.
COVID-19 continues to present challenges, and
even when we emerge from the pandemic, we face
a permanently changed healthcare market. A 2021
Mercer study, US Healthcare Labor Market, found
that “by 2026, it is estimated that 23,000 primary
care physicians will permanently leave the profession,
leaving a vacuum of demand for primary care
providers. More and more often, physician assistants
(PAs) and nurse practitioners (NPs) will step in to fill
that demand. About 40,000 new PAs and NPs enter
the workforce annually, providing a steady stream of
new entrants who are qualified and ready to fill the
extra demand resulting from retiring physicians.” This
data only reinforces the recent permanent change
in federal law and further highlights the need for
Missouri lawmakers to follow suit. We must take this
opportunity where we can make decisions now that
will help address the coming physician workforce issue
and put a process in place that will not only improve
the continuity of care but will continue and enhance
the home health benefit for patients.
The federal government, through bi-partisan
efforts, recognized APRNs and PAs inability to sign
home health orders as a potential delay in care,
increased risk of poor outcomes and increases in the
cost of care and took the steps to permanently make
the change in federal law. It is time Missouri lawmakers
put patients over politics and allow Missouri’s home
health statute to include APRNs and PAs ability to
certify home health services.
Respectfully Submitted,
Carol Hudspeth, Executive Director
Missouri Alliance for Home Care
MONA’s Mission, Vision, Purpose
Our Mission
Registered Professional Nurses advancing the profession to
improve health for all Missourians
Our Vision
Missouri nurses are a powerful, unified force engaging
consumers and transforming health and health care.
Our Purpose
To act and speak for the nursing profession and Missouri’s
professional nurses and to promote and enhance safe and
accountable professional nursing practice.
MONA’s Official Publication:
The Missouri Nursing News is an official publication of the
Missouri Nurses Association (MONA) (a constituent member
of the American Nurses Association), published quarterly
every January, April, July and October. The MONA provides
education, networking opportunities, publications and
other products and services to its members and extends its
mission to all nurses in Missouri.
Phone: (573) 636-4623
Email: director@missourinursess.org
Web site: www.MissouriNurses.org
Mail: c/o Midwest Multistate Division
3340 American Avenue, Suite F
Jefferson City, MO 65109
Questions about your nursing license?
Contact the Missouri State Board of Nursing at:
(573) 751-0681.
This newsletter is a service of the Missouri Nurses
Association and your receipt of it does not mean
you are automatically a member. Your membership
in support of this work is encouraged; please visit
www.missourinurses.org.
Writer’s Guidelines:
• Any topic related to nursing will be considered for
publication in the Missouri Nursing News.
• Authors are not required to be members of the MONA;
however, when space is limited, preference will be given
to MONA members.
• Photos are welcome, digital is preferred. MONA does not
assume responsibility for lost or damaged photos.
• Use current APA formatting for any article requiring
citation.
• Provide a brief author biography indicating the author’s
nursing experience and/or expertise with the paper’s
content.
o Limit the author’s biography to 4-sentences.
• Submitted material is due by the 10th of the month in
March, June, September and December of each year.
• The peer-review is blinded; submit the title page
separately from the article
• Submit the title page and article as Word documents to
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liable for any consequences resulting from purchase or use of
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express the opinions of the authors; they do not necessarily
reflect views of the staff, board, or membership of MONA or
those of the national or local associations.
January, February, March 2022 Missouri Nursing News 3
What is Value-Based Purchasing?
Sarah Oerther, Ph.D., RN, ANEF
Since 2019, in the United States, people older
than 65 years of age have outnumbered those
younger than five years of age, and this trend is true
in Missouri (United States Census Bureau, 2021). As
Missouri residents live longer and age, more of them
will develop multiple chronic conditions, such as heart
disease, dementia. Many also will develop functional
limitations, including difficulty with the activities of
daily living such as managing one’s household due to
a lack of mobility. Researchers have found that patients
who can remain in their home with support services
benefit in multiple ways (Landers et al., 2016; Pozniak
et al., 2021). For example, often they receive more
personalized care, maintain greater independence,
are safer and more comfortable, and have a decrease
in unnecessary trips to the hospital. Collectively, these
benefits may delay or even prevent admission to
assisted living and nursing home facilities, which often
are more expensive forms of care as compared to the
provision of support services in the home. On the
other hand, the provision of support services in the
home may be subject to fewer quality controls because
healthcare providers traveling to homes may have less
support from and supervision from peers as compared
to facility-based care (Landers et al., 2016; Pozniak et
al., 2021).
To help ensure the quality of the provision of
support services in the home, in 2016 several states
began to implement the Home Health Value-Based
Purchasing (HHVBP) Model developed by the Centers
for Medicare & Medicaid Services (CMS) (The Centers
for Medicare & Medicaid Services, 2021). "Valuebased
purchasing," also known as pay for performance
(P4P), is a model of payment that offers financial
incentives to physicians, hospitals, medical groups,
and other healthcare providers for meeting certain
performance measures (Chee et al, 2016; Landers et
al., 2016). Clinical outcomes, such as longer survival,
are difficult to measure. Therefore, pay for performance
systems usually evaluate process quality and efficiency,
such as measuring blood pressure, lowering blood
pressure, or counseling patients to stop smoking. In
addition, this model penalizes health care providers
for poor outcomes, medical errors, or increased
costs. Integrated delivery systems where insurers and
providers share in the cost are intended to help align
incentives for value-based care (Chee et al, 2016; The
Centers for Medicare & Medicaid Services, 2021).
The HHVBP Model was designed to give Medicarecertified
home health organizations incentives to
deliver high quality and efficient care (The Centers
for Medicare & Medicaid Services, 2021). By adjusting
payments based on the quality of care, rather than
the quantity of services provided, the HHVBP Model
enables CMS to tie home health organizations’
payment to their performance. To support the efforts
of the Department of Health and Human Services,
the HHVBP Model helps to spend healthcare dollars
wisely. This includes supporting efforts to deliver better
overall care, which contributes to healthier people and
communities (Landers et al., 2016; The Centers for
Medicare & Medicaid Services, 2021).
In November 2021, the CMS acted to improve home
health care for older adults and people with disabilities
through a final rule, which aims to shift payments from
a volume-based system to a value-based system for
Medicare sponsored home health services. Nationwide,
the HHVBP Model provides a critical update to the
Home Health Prospective Payment System (PPS). This
includes updates to the payments rates for home
infusion therapy services for Calendar Year (2022).
All these changes have been designed to harmonize
with existing statutory and regulatory requirements,
nationwide (The Centers for Medicare & Medicaid
Services, 2021).
One of the greatest health care challenges facing the
State of Missouri is making sure that aging adults with
multiple chronic illnesses can remain as independent
as possible. Nurses need to understand these changes
to reimbursements for the provision of home health
services and respond accordingly. As nursing continues
to meet the challenge of providing affordable health
care to aging adults in their homes, nurse educators
should look to the guidance offered in the Future of
Nursing 2030 Report and expanding the training of
future nurses to continue to work effectively at the
clinical bedside and beyond.
References
Chee, T. T., Ryan, A. M., Wasfy, J. H., & Borden, W. B.
(2016). Current state of value-based purchasing
programs. Circulation, 133(22), 2197–2205. https://doi.
org/10.1161/CIRCULATIONAHA.115.010268
Landers, S., Madigan, E., Leff, B., Rosati, R. J., McCann, B.
A., Hornbake, R., MacMillan, R., Jones, K., Bowles, K.,
Dowding, D., Lee, T., Moorhead, T., Rodriguez, S., &
Breese, E. (2016). The future of home health care. Home
Health Care Management & Practice, 28(4), 262–278.
https://doi.org/10.1177/1084822316666368
Pozniak, A., Lammers, E., Mukhopadhyay, P., Cogan, C.,
Ding, Z., Hanslits, K., Ji, N., Jin, Y., Repeck, K., Schrager,
J., & Turenne, M. (2021). Impacts of the home health
value-based purchasing ( HHVBP ) model after the first
payment adjustment year. Health Services Research,
56(S2), 72–72. https://doi.org/10.1111/1475-6773.13799
The Centers for Medicare & Medicaid Services. (2021). Home
health value-based purchasing model: CMS Innovation
Center. Innovation Center. Retrieved from https://
innovation.cms.gov/innovation-models/home-healthvalue-based-purchasing-model.
United States Census Bureau. (2021). U.S. Census Bureau
quickfacts: Missouri. Retrieved from https://www.
census.gov/quickfacts/MO.
4
Missouri Nursing News January, February, March 2022
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January, February, March 2022 Missouri Nursing News 5
Think like an expert witness to avoid falls liability
An 88-year-old patient slips on the floor, falling and
breaking his hip. Your immediate concern is getting
him the help he needs, but you also wonder if you
could be legally liable for what happened. By thinking
like an expert witness, you can help determine if this
concern is valid and whether you could have taken
steps to avoid the situation in the first place. But first,
you need to understand some background information.
Elements of malpractice
To be successful in a malpractice lawsuit, plaintiffs
must prove four elements:
1. Duty. A duty existed between the patient and
the nurse: The nurse had a responsibility to care
for the patient.
2. Breach. The duty to care was breached. To
determine if negligence occurred, the expert
witness would consider whether the nurse met
the standard of care, which refers to what a
reasonable clinician with similar training and
experience would do in a particular situation.
3. Injury. The patient suffered an injury. Keep in
mind that an injury can be defined as not only
physical injury, but also psychological injury or
economic loss.
4. Causation. The breach of duty caused the
injury: Did the act or omission cause the negative
outcome?
Expert witnesses will consider these four elements as
they review the case, and they’ll ask multiple questions
(see Was there liability?). The questions primarily
address prevention and what was done after the fall
occurred.
Prevention
The following steps can help prevent falls and,
if documented correctly, prove that the nurse took
reasonable steps to protect the patient from injury:
Take a team approach. Registered nurses, licensed
practical/vocational nurses, and certified nursing
assistants are ideal members for a team dedicated to
creating a falls reduction plan for each patient.
Assess the risk. A comprehensive assessment
is essential to identify—and then mitigate—falls
hazards. This starts with assessing the patient for risk
factors such as history of a previous fall; gait instability
and lower-limb weakness; incontinence/urinary
frequency; agitation, confusion, or impaired judgment;
medications; and comorbid conditions such as postural
hypotension and visual impairment. Keep in mind that
assessment should be ongoing during the patient’s care
because conditions may change. It’s also important
to consider the environment, particularly in the home
setting.
An excellent resource for assessing communitydwelling
adults age 65 and older is the CDC’s STEADI
(Stopping Elderly Accidents, Deaths & Injuries) initiative.
Develop a plan. Once the assessment is complete,
the patient care team, including the patient and their
family, can develop a falls-reduction plan based on the
patient’s individual risk factors. The plan should address
locations that are at greatest risk, such as bedside,
bathrooms, and hallways, and detail action steps.
Communicate. It’s not enough to create a plan;
communication is essential for optimal execution.
All care team members, including patients and their
families, need to be aware of the patient’s fall risk and
the falls reduction plan. The STEADI initiative has falls
prevention brochures for patients and family caregivers
at www.cdc.gov/steadi/patient.html. The falls risk
reduction plan, communication with others, and
education provided should all be documented in the
patient’s health record.
If a fall occurs
Despite nurses’ best efforts, a patient may fall. An
expert witness will scrutinize how the nurse responded
to the event. The following steps will help to reduce
the risk of a lawsuit or the chances that a lawsuit is
successful:
Assess the patient. Examine the patient for any
obvious physical or mental injuries. Do not move
the patient if a spinal injury is suspected until a full
evaluation can be made. Be particularly alert for
possible bleeding if the patient is taking anticoagulants.
When appropriate, ask patients why they think they fell
and continue monitoring at regular intervals.
Communicate assessment results. Notify
the patient’s provider of the fall and results of the
assessment. The provider may order X-rays for further
evaluation. Remember to mention if the patient is
taking anticoagulants, particularly in the case of a
potential head injury, so the appropriate scans can be
ordered.
Revise the plan. As soon as possible after the fall,
work with the team to reassess risk factors, revisit the
falls reduction plan, and revise the plan as needed. It’s
important that actions are taken to prevent future falls,
and that those actions are documented.
Document. Each step should be documented in the
patient’s health record, especially all assessment results
and provider notifications.
Reducing risk
Unfortunately, patient falls are not completely
avoidable. However, developing a well-conceived
prevention plan can help reduce the risk, and taking
Think like an expert witness to avoid...continued on page 6
6
Missouri Nursing News January, February, March 2022
Think like an expert witness to avoid...continued from page 5
appropriate actions after a fall can help mitigate further
injury. Both prevention and post-fall follow up not only
benefits patients, but also reduces the risk of a lawsuit.
Was there liability?
If a patient falls, an expert witness will likely want
to know the answers to the following questions
(developed by Patricia Iyers) when deciding if liability
may exist:
• Was the patient identified as being at risk for
falls? How was that risk communicated to
others?
• Were measures implemented to prevent falls?
• Approximately how soon was the individual
found after he had sustained a fall?
• What was done at the time of the fall?
• Was the patient appropriately monitored after
the fall to detect injuries?
• What did the assessment (including vital signs)
reveal?
• Did the nurse communicate the findings to the
patient’s provider?
• Were X-rays ordered and performed?
• Was there an injury? If so, how soon was it
treated?
• If the patient hit their head, was the chart
reviewed to determine if mediations included
an anticoagulant? If on anticoagulant, was this
information communicated to the provider so
head scans could be performed to check for
cranial bleeding?
• Was there a change in mental status after the
fall?
• Were additional assessments and monitoring
done as follow up?
• Was the patient’s risk for falls reassessed after
the fall and the plan of care revised to minimize
the risk of future falls?
Article by: Georgia Reiner, MS, CPHRM, Senior Risk
Specialist, Nurses Service Organization (NSO)
RESOURCES
Bono MJ, Wermuth HR, Hipskind JE. Medical malpractice.
StatPearls. 2020. www.ncbi.nlm.nih.gov/books/
NBK470573.
Centers for Disease Control and Prevention. Important facts
about falls. www.cdc.gov/homeandrecreationalsafety/
falls/adultfalls.html.
Centers for Disease Control and Prevention. STEADI:
Materials for healthcare providers. 2020. www.cdc.gov/
steadi/materials.html.
CNA, NSO. Nurse Professional Liability Exposure
Claim Report: 4th Edition. 2020. www.nso.com/
nurseclaimreport.
Dykes PC, Adelman J, Adkison L, et al. Preventing falls in
hospitalized patients. Am Nurs Today. 2018;13(9):8-13.
https://www.myamericannurse.com/preventing-fallshospitalized-patients.
Iyer P. Legal aspects of documentation. In: KG Ferrell, ed.
Nurse’s Legal Handbook. 6th ed. Wolters Kluwer; 2015.
Van Voast Moncada L, Mire GL. Preventing falls in older
persons. Am Fam Physician. 2017;96(4):240-247. https://
www.aafp.org/afp/2017/0815/p240.html.
Disclaimer: The information offered within this article
reflects general principles only and does not constitute legal
advice by Nurses Service Organization (NSO) or establish
appropriate or acceptable standards of professional conduct.
Readers should consult with an attorney if they have specific
concerns. Neither Affinity Insurance Services, Inc. nor NSO
assumes any liability for how this information is applied in
practice or for the accuracy of this information.
This risk management information was provided by
Nurses Service Organization (NSO), the nation's largest
provider of nurses’ professional liability insurance coverage
for over 550,000 nurses since 1976. The individual
professional liability insurance policy administered through
NSO is underwritten by American Casualty Company of
Reading, Pennsylvania, a CNA company. Reproduction
without permission of the publisher is prohibited. For
questions, send an e-mail to service@nso.com or call 1-800-
247-1500. www.nso.com.
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January, February, March 2022 Missouri Nursing News 7
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Missouri Nursing News January, February, March 2022
MONA Member Benefit for
ANCC Certification
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Members of the Missouri Nurses Association also receive a reduced rate
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January, February, March 2022 Missouri Nursing News 9
In his seminal work, Diffusion of Innovations,
Everett Rogers found that for a new idea to be widely
adopted, it has to meet four basic criteria:
1. It has to be innovative.
2. It has to be communicated through certain
channels.
3. It has to occur over time.
4. It has to happen among the members of a social
system.
Victor Hugo is credited with the observation that
there is nothing so powerful as an idea whose time
has come. Unfortunately, until their time arrives, the
best ideas can repeatedly fail to launch for decades.
You may be familiar with the case of James Lancaster,
an English sea captain who suspected that citrus juices
prevented scurvy in his sailors (this idea occurred to him
at a time when scurvy killed more sailors than warfare
or sea accidents). Today, we know he was correct. As
early as 1601, he proved his theory with real sailors and
a control group. Even so, his innovation failed to catch
on.
Finally, in 1747 (150 years later), a British Navy
physician, James Lind, read about Lancaster’s
experiments & began some of his own. Lind’s
experiments also proved the theory. It was so
undeniable, the British Navy ultimately required
oranges, lemons & limes for sailors on its entire fleet
of ships, to prevent scurvy among its sailors… in
1795, nearly 50 years after this re-discovery of James
Lancaster’s original experiments.
You may wonder why, in the face of so many
deaths, when the answer was so simple, it took two
centuries for this medical innovation to catch on. In
short, bureaucratic inertia was a major barrier. There
was evidence that citrus prevented scurvy, but not
everyone agreed it was a cure. Further, Dr. Lind may
have been correct, but he was not a prominent figure
in Navy medicine, so his message was slow to gain
traction. One thing we know for sure: During the
intervening 200 years, the Navy adopted numerous
innovations in shipbuilding & weaponry. It was simply
not the case that the Navy was averse to innovation in
general.
One of the most important roles of the Missouri
Nurses Association is our promotion of innovation in
the field of Nursing. One way we do this is by offering
an Early Career Nurse Innovator Award – an annual
cash prize for a creative new nurse, who looks at the
profession with fresh eyes, whose innovative approach
accomplishes something noteworthy & respectable that
advances the profession of Nursing & the health of
Missourians.
This year, we are using a somewhat innovative
approach to fundraising for the grant. We are asking
100 people to donate $100 to support the Early Career
Nurse Innovator Award. As leaders in the social system
of Nursing, we believe that by communicating these
innovative acts to & through our members & our
colleagues over time, we’re well-positioned to help
these innovations diffuse in the time-tested manner
supported by research. We are asking you to visit our
website & make a $100 donation to our effort, and to
send this letter to a couple of your friends, encouraging
them to consider doing the same.
To give, please visit: https://missourinurses
foundation.org/100for100/
With your help, as always, we hope to connect the
past, improve the present & anticipate the future of
Nursing in Missouri.
Thank you,
Matt Younger, M.S., LNHA
President, Missouri Nurses Foundation
10
Missouri Nursing News January, February, March 2022
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January, February, March 2022 Missouri Nursing News 11
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