Creating the rehab-oriented nursing staff.

rehabilitation services can be the future, but not until existing nursing staff signs on

Developing high-quality, successful rehabilitation programs is a goal of many administrators searching for the "perfect niche" for today's skilled nursing facility. Each wishes to focus the community's spotlight on his or her facility as the prime location to refer patients needing exemplary rehab care. The caliber of the rehab professionals employed has, of course, a definitive effect on the quality and success of this effort - but this depends decisively on the understanding and cooperation of the facility's nursing department. It is a total-facility effort.

To begin to achieve this, the administrator must clearly define why rehab is the facility's chosen direction. Hopefully, he or she understands that quality of service reaps a wealth of rewards, not the least of which is enhanced income per patient. But more important, quality therapeutics leads to healthier, higher-functioning patients, thus resulting in greater patient, family and community satisfaction. That imparts improved marketability, thereby resulting in better census totals and mix, which in turn enhances earnings. To complete the classic cycle, rewarding the profitable facility enables its staff to deliver superior patient service.

The administrator must also promote the specific benefits of being rehab-oriented. With the size and influence of the nursing department, the pivotal person in this effort is the Director of Nursing. He or she acts as the fulcrum to maintain balance among all entities delivering care. Concerning rehab, nursing staff often complains that such programs simply increase nursing workload. The counter to this is that patients with better health require less nursing intervention over the long run. Thus, the DON should seize the opportunity to coordinate the facility's overall efforts to return patients to their highest functional level in the minimum time needed.

With key rehab personnel, the DON should scrutinize each admission inquiry for rehab potential, in addition to the myriad other therapeutic parameters necessary for admission. If the patient is approved for admission, the rehab team should be notified of each patient's anticipated arrival date and diagnosis. Then, upon admission, each patient's anticipated discharge plan should be crystallized and precisely documented, usually in conjunction with the social service staff during (at least) weekly patient care plan meetings. Direct care providers (supervisors, medication and treatment nurses, CNAs) should provide their input into this forum. This encourages staff "ownership" of the rehab focus, which should generate excitement and a sense of accountability. (Staff not in attendance must be informed of the plan to design their care role commensurately.) The idea is to have the patient care plan correspond to the discharge plan as closely as possible, the goal being to expedite discharge as appropriate.

The next step in coordinated planning is the weekly rehab meeting. The rehab meeting is an important forum for the rehab staff to develop, monitor, modify and re-monitor optimal treatment plans to equip each patient with skills necessary to achieve his or her maximum potential, commensurate with the discharge plan. With attendance by the DON and key nursing personnel, tremendous interdisciplinary rapport can be established, as these staff communicate and work toward common goals. Directed by the objectives developed at this meeting, nursing staff can monitor each patient's course with far more awareness and clarity than if such teamwork did not exist. Staff will feel more confident in adopting a more individualized approach to care.

In a successful rehab program, the patient's overall health - its physical, mental and emotional components - will all improve more dramatically than could ever be expected without rehab involvement. This, as noted, is a prime "selling point": nursing staff chose their profession to enjoy the rewards of improving the well-being of the people for whom they care. Nothing in the long-term care environment is more gratifying, motivating or exciting to nursing staff than returning patients to a lower level of care through their active involvement.

The DON has continuing responsibilities in maintaining this process. He or she should continually assess the skills of the facility's supervisors, charge nurses and director of staff development to ensure that they continue to clearly comprehend the facility's rehab focus. The DON must monitor and help guide the nursing assistants to properly care for each patient, while making sure they receive input regarding patients' progress and changes of condition.

One idea worth considering: Many facilities employ one, two or three restorative nursing assistants. A creative alternative might be to train all nursing assistants to be RNAs, assign them the operational and documentation duties of an RNA, and return the one, two or three staffing positions to the nursing assistant daily staffing. Nursing assistants usually respond very favorably to new duties such as this - they expand their perspectives, and generate excitement and pride from involvement in the improvement-focused process of rehab.

A final note: Nothing will dispel nursing homes' unfortunate "warehousing" image, perceived by much of the public, like a successful rehabilitation program. Appropriate education and training of staff, begun at the executive level, encourages thorough communication, more intensive involvement, more skilled clinical intervention and, in the end, healthier patients. That is the aspiration of all dedicated staff members working in skilled nursing facilities, and it is - or will become - the expectation of the communities we serve.

David Lefitz is President of ProRehab, Inc., a Westlake Village, CA-based speech therapy provider for skilled nursing facilities in California. The company helps clients to develop new rehabilitation services or improve existing ones. For further information, [phone].