Gleanings from the new world of subacute.

Random views on recent developments

As subacute care continues to evolve, what are nursing homes learning? What new issues are they confronting, new organizational problems, new technologies? We asked several randomly selected consultants and vendors about this, and found that developments are progressing rapidly. Involved nursing homes are finding their staffing, technology and financial prospects changing in ways they could not have anticipated only a few years ago. Comments from recent phone interviews:

Kathi Thimsen-Whitaker, RN, Whitaker Consultants, Belleville, IL (wound care): "First of all, there are many more board-certified enterostomal therapy (ET) nurses available now than there were just a few years ago. Where there were perhaps five private ET consultant practices in the United States five years ago, now there are at least 20. Good ET consultation can be readily at-hand by contacting the Wound Ostomy Continence Nursing Society in Irvine, CA or even a state Division of Aging for references.

"Technology in this field is evolving all the time. Probably the leading developments now focus at the cellular level of tissue healing - growth factors, growth-enhancing formulas, even 'smart dressings' that monitor wound healing and signal to the clinician what step to take next. Much of this is experimental right now. Currently available, though, are new wound hydrogels that feature specific ingredients offering new benefits. For example, products that include hyaluronic acid and fibronectin, which have been used in utero to heal babies with cleft palate, are now available on the wound care market.

"On the downside, though, there is a danger that this market is becoming product-driven rather than patient-driven. The whole process begins and ends with the patient's needs, and as more products get covered by insurance, we can lose sight of that. There is also a rapidly-developing ethical dilemma in this field: what if patients who say they want no heroic measures taken - no tube feeding, for example - end up with skin breakdown as a result of this, and these highly effective - and expensive - treatments are readily available to treat them? Are you liable if you don't use them - or if you do use them? There is a growing concern about questions like these."

Cheryl Riley, RN, National Director of Clinical Operations, Infu-Tech. Inc., Englewood Cliffs. NI (infusion therapy): "The key factor nursing homes still must confront is appropriate staffing. Nurses who provide infusion therapy must be trained and must want to work with these types of cases. If you have a traditional DON and nursing staff who want only to do long-term care, you will never succeed with subacute infusion therapy.

"The positive side is that there are many more qualified nurses available now than before. They're being laid off by hospitals, they find home care too time-consuming, and they want something steadier than part-time nursing pools. Many of these nurses are willing to at least look at nursing facilities as a possible opportunity. On the other hand, they must be paid appropriately, and they need opportunities for continuing education and advancement. Without these, nursing homes will have, and are having, a very difficult time recruiting qualified staff. With adequate pay and educational opportunities, though - and some nursing homes we work with do have these - you find that staff morale is high, and they really want to stay with the facility and do a good job.

"This is vitally important because, if you don't provide subacute services appropriately, you will end up with excessive hospital readmissions and costs that are higher than ever, and you will fail.

"For educational resources, owners and operators might turn to local and state chapters of associations, such as the Intravenous Nurses Association, the Oncology Nurses Society, the American Society of Parenteral and Enteral Nutrition and the American Association for the Care of AIDS Patients.

"On the technological side, recent developments include high-tech pumps, such as Verifuse, where flow rates can be re-programmed by a supervisor or consultant pharmacist over the phone. This makes supervisors' lives much easier when patients' needs rapidly change. We have also seen a 'positive step backwards,' technologically speaking, in pole-mounted pumps. For years these became increasingly complex and difficult to use, especially for staff, such as those in nursing homes, who use them only occasionally. Some manufacturers have noted this and are now marketing pole-mounted pumps that are simpler to use and do a good job in this setting.

"As the successful nursing homes progress with infusion therapy, they're going to be doing more and more oncology care and postoperative care, and blood transfusions as well. The prospective case load is out there, and it is available to the nursing home that is appropriately staffed and motivated."

Fred Stern, President, UltraCare, Boston MA (rehabilitation): "Rehabilitation patients always were subacute patients, in a sense, but the intensity of rehab in the nursing home has increased and expected length-of-stay is steadily decreasing. Many hip fracture cases, for example, are expected to be discharged within 15 to 30 days. And that means PT and OT staff must be intensified and brought up to speed. There is also growing demand for outcomes data - comparing, for example, the results of licensed therapists vs. licensed assistants. Accreditation is also becoming more important. JCAHO accreditation is now being required by some managed care companies, and CARF accreditation is useful, as well. The major change that nursing homes now face is the growth of Medicare managed care. Medicare is the largest payer for subacute services, and managed care has a very active interest in the market."

Connie Gray, New England Divisional Vice-President, Sundance Rehabilitation Corp. (rehabilitation): "The staffing and capabilities of some nursing facilities are growing rapidly. We have one 350-bed facility that has 90 beds dedicated to subacute rehab and 35 full-time therapists. Several of our subacute-oriented facilities are moving toward establishing therapist teams combining PT, OT, speech therapy and respiratory therapy, and focusing on pulmonary rehabilitation, such as ventilator weaning. These changes affect not only clinical staff, but front office staff as well. One major need many of these facilities have is staff to process as many as 50 admissions and discharges per month and all the billings that go with this. They are also adding case management, which commercial insurers and managed care want in order to coordinate care.

"We're seeing dramatic increases in space devoted to rehab, with treatment units as large as 5,000 square feet being built or converted, and including all the basic technology - hydrotherapy, treadmills, pulse oximeters, etc. - that these patients need. Another development is critical pathways, outlining therapy for, for example, hip fracture repair and postop hip and knee replacement. Critical pathways not only increase treatment efficiency, but enable you to price and market the care you provide very specifically.

"We're starting to see development of multi-level campuses, which include a skilled nursing facility, a retirement community, assisted living, home health care and outpatient services. Having this continuum of care appeals to therapists and helps in staff retention. Other 'cutting edge' developments are direct admissions from emergency departments and post-ambulatory surgery follow-up, both of which are of interest to managed care."

Tommy Rust, Regional Vice-President, Primedica (respiratory): "Probably the most significant recent development in respiratory care services is the increased acuity of the patients we are seeing. We are seeing patients that, five years ago, would have been in the ICU, and many would have been deemed unweanable from the respirator. Because of the resources we can bring to bear in the skilled nursing facility-based unit, we are able to wean these patients much more cost-effectively. In hospitals, typical staffing ratios are one therapist to 12 or 15 patients, and in the ICU it is one to eight. In the subacute unit we have one therapist for every four or five patients tops. This means we can focus on each patient's individual needs, learn what they can and cannot tolerate, and both treat their immediate needs and wean them at a lower cost than in the hospital setting. This also helps the hospital cope with its DRG requirements. That's why it makes good sense for a hospital to form liaisons with skilled nursing facility units that are equipped and staffed to provide this level of care."

Gay Shoup, Senior Vice-President for Marketing. Sunrise Healthcare Corp. (general subacute): "Subacute services are a major investment for nursing facilities, but it's justified, because there is a huge window of opportunity out there and it's getting bigger, as managed care gets more involved. The subacute medical side is expanding quite rapidly. Nursing homes are seeing types of medical patients they've seldom, if ever, seen before: oncology therapy, AIDS crises, burn care (evolving from wound care) - even high-risk pregnancy.

"On the rehab side, we're seeing demand for more intensive services for such conditions as head injury, spinal trauma, coma, amputations, and so forth - seven-day-a-week patients requiring appropriate staffing and space. The demand is there because people are finding that skilled nursing facilities can deliver this care more cost-effectively than rehab hospitals."