Health care continuum.

Everyone talks about the "continuum." Here's how nursing homes can do something about it

Health care reform is dramatically changing the way care will be delivered in the future. We have recently heard about the guiding principles that President Clinton will use to shape his health care reform bill -- universal access, managed care and cost containment -- and a myriad of ideas are being proposed to implement the changes.

One that has been taken hold of by healthcare professionals and lauded as a key to the future is the integrated coordination of care: the concept of a continuum. It is a commonly used phrase that transcends all forms of health care. How might it apply to long-term care?

General Definition

A continuum of aging services is a comprehensive and integrated network of services that guides and tracks patients/clients over time and includes acute, transitional, long-term and preventive care. An integrated continuum requires active collaboration among local providers in two general groups. The first includes hospitals, nursing homes, retirement communities, physicians and home health services. The second group is social or community-based service.

Currently, the typical "continuum" is incomplete and disjointed, with only a few pieces in place. It is important to remember, though, that it is not necessary to have all parts of the continuum available to serve patients and their families. Indeed, many providers may only offer one piece of a continuum, while others may have several. What is critical to understand is that linking with other community services to provide a continuum which benefits patients, payors and providers will be the design of the future.

Specifically, one provider can take ownership of the continuum by initiating linkages with other providers, or that provider can become a link in another organization's continuum through a service contract. It is not unusual for a nursing home to do both.

Collaboration is what holds a successfully implemented continuum together. Whereas the 1980s were characterized by competition among discrete facilities, this decade will be known as one of strategic collaboration. Working together can benefit everyone, and this is particularly true in the long-term care industry.

Why Participate in a Continuum?

There are five major reasons for considering involvement with a continuum of care:

1. Provider Referrals

Being part of a continuum has several marketing advantages. It allows you to assure families that you will be able to care for their loved one over time and that they will be relieved of the pressure of further placement decisions and efforts. Additionally, having established relationships with other providers to whom you will be directing residents will increase their level of awareness of your services and may result in a reciprocal referral network.

2. Added Revenue

The creation of a continuum can provide additional revenue opportunities for you as a provider. You create new services or offer them through another provider and thus increase the length of stay of current residents as well as attract new ones.

3. Changing Resident Needs

Maintaining census is a way of life in all long-term care facilities. We all know that residents' needs change over time. Sometimes the changes are temporary, sometimes permanent. If your facility is part of a continuum, the transition from one level of care to another, or from one facility to another, can be done smoothly, with a minimum of disruption to the resident and family.

4. Maximizing Resident Independence

The quality of life of the resident and family is enhanced when the resident is receiving the appropriate level of care for his or her condition. This is true in all areas of the continuum, but is especially relevant in the areas of specialty care and hospice.

5. Reduced Cost of Care

Placement of a senior in the least acute level of care needed reduces overall costs of health care and enables all providers in the continuum to be perceived in a more positive light by the public, by payors and by regulators.

In pursuit of these goals, a provider can have a variety of formal and informal relationships with other providers in the community. Some common examples of linkages are "preferred provider" agreements where a senior housing facility establishes an exclusive relationship with a particular nursing home to arrange priority access for its residents, or a hospital discharges patients to selected nursing facilities in the geographic area it serves. Another example would be an agreement between a nursing home and a home health agency to provide services to the residents on a fee-for-service basis.

First Steps in Getting Started

Given the benefits of participating in a continuum of care, how can a nursing home become involved? The first steps in getting started are to:

Identify all of the needs of an older adult

* Identify all community providers and their service offerings

* Identify and assess your existing services

* Identify unmet needs and gaps in services

* Evaluate your capability to provide the missing services

* Complete a financial feasibility study to evaluate whether you should add the service yourself or link with another provider

At this point, if you decide that collaboration is the way to go, you should carefully investigate possible partners and evaluate them. Choose your partners wisely, using a number of criteria for selection. A consideration in building linkages is understanding the unique perspectives of the other players.

For example, although the acute care piece is critical to any continuum, it is sometimes difficult to imagine partnering with a hospital because of its size and perceived bureaucracy. With decreased lengths of stay, reimbursement and severity of discharges, hospitals are very willing to look to nursing homes as an extension of their services. There are several key factors in successful partnering:

* You need to know the other provider, trust them and respect their ability to care for patients.

* You need to have a mutually agreed upon vision and goals.

* The relationship must be mutually beneficial. There should be shared risk and reward. No linkage can be successful over time if one party benefits or suffers unequally.

* Decision making should be shared within predetermined lines of authority.

* Communication is an essential part of collaboration. Meet regularly to discuss how things are going, and what needs to be changed.

Innovative Applications

In recent years, the continuum has been applied in innovative ways to link established categories of care. Sections such as subacute, assisted living, adult day care and home care are all components which are getting a lot of attention lately. A key issue with components such as the assisted living option is that their short-term transitional patient stays require a continuum involving nursing homes. This is why owners must not look at their facility in isolation any more, but rather as a part of a community effort.

Adult day care has been around for quite a while, but lately it has drawn more attention as a lower-cost, "lower-tech" service delivery site. There are several providers that have added adult day care to their long-term care facility or have partnered with an adult day care provider in their community.

Lutheran General HealthSystem was one of the pioneers in adult day care. It has a medical model and currently operates four sites. Several years ago, through a collaborative partnership, a skilled nursing facility in the community and the day care center started a program which offered residents of the nursing facility an opportunity to spend time at the day care center, availing themselves of all of the activities offered and returning to the nursing facility at night. The day care center provided transportation.

This program resulted in a win-win situation for providers, residents and families. Both facilities were able to enhance their own programs by offering this unique service. The nursing home generated awareness among adult day care participant families who were a very appropriate audience and the day care center gained private pay clients from the nursing home.

The day care/nursing home linkage is a natural one and a valuable partnership for long-term care providers. Although day care is often a step that families take to postpone a nursing home placement, familiarity with an area provider in an informal setting can lead to nursing home placement on a permanent or respite basis. For example, a day care center could link with a nursing home in order to provide 24-hour respite care for its caregiver families. Indeed, respite care is a service that is growing in popularity.

Another growth area is the proliferation of subacute and specialty facilities. These are components of the continuum that nursing homes can appropriately develop themselves or seek through linkage with another provider. For example, a skilled nursing home in a suburban community with a census in the 80 percent range recently refined its services to only subacute nursing care. The existing lower level patients were transferred to neighboring providers. This facility repositioned itself as caring for only patients requiring ventilators, feeding tubes or other high-tech assistance.

Because creating this niche was unique in the nursing home's market area, the facility gained preferred access to a group of patients who were not suitable to other competitors. Now, other area providers see this facility as a resource, not as competition. They send their very sick patients to this facility. After a short stay they are transferred back to the other nursing home. Often hospitalized patients, as well, are directed to this facility immediately upon discharge. Patients that come directly to the subacute facility are often transferred to regular skilled facilities, therefore providing them with a new source of patients. Again, a win-win for both providers and patients is accomplished.

The hospice movement has made tremendous strides in terms of helping patients and families deal with terminal illness. A nursing home that sets up a hospice program can extend the stay of its own patients who are in the later stages of terminal illness, as well as receive transfers from acute care institutions and other long-term care providers without hospice.

A major demographic segment which will determine a large part of the future for continuum services will be the 80 percent of older adults who want to continue to live in their own homes by utilizing support services as needed. These at-home services can be high-tech, such as infusion therapy, or something as simple as chore service. These types of services stand to benefit considerably from the Clinton Administration's health reform initiatives. There is no reason why a nursing home cannot be the hub of these services by reaching out to the community and coordinating their provision for people living in the surrounding area. By becoming the headquarters for a community outreach program such as this, nursing home operators can earn the trust and loyalty of neighborhood seniors who may become prospective residents in the future.

Clearly, nursing homes are a critical and necessary component of any health care continuum. The time has come to maximize their role in ways that will benefit both the facility and the residents and families served.

Robert L. Clapp is President of Parkside Senior Services, Park Ridge, IL, a division of The Parkside Company, and has had 20 years experience in developing innovative nursing home and retirement community programs. He has served on the Connecticut State Board of Licensure for Nursing Home Administrators.