Improving professional collaboration in today's nursing home.

In a perfect world, nursing home professionals would work together like a well-oiled machine for the common good of their residents. Quality Assurance meeting attendance would be standing-room only, and all problems would be resolved with smooth professional teamwork. Personality clashes, blaming and all forms of territorial behavior would, of course, be a distant memory. Interdisciplinary harmony would reign.

Now for the real world: financing and resident care issues sometimes pitting one department against another; the pressures of reimbursement constraints, combined with demands for new levels of care, placing still greater strains on what may already be fragile professional relationships.

If some nursing homes are able to rise above these difficulties and function effectively as professional teams of compassionate and efficient providers, it's not a matter of luck. A concerted effort was required on the part of all those involved. In the following article, four professionals intimately attuned to the difficulties involved -- an administrator, a director of nursing, a medical director and a consultant pharmacist -- share their suggestions for improving professional collaboration.

Panelists include:

Carol F. Sabella: Administrator of Hopkins Manor, a 210-bed nursing home in North Providence, RI. She began her 26 years in long-term care as a nurse's aide and dietary aide and has moved up the ranks as an LPN, RN and DON.

Richard Neufeld, MD: full-time Medical Director for the past 12 years at the Jewish Home and Hospital for Aged, a 500-bed teaching nursing home affiliated with the Mount Sinai School of Medicine in New York City.

Julie Ditzler, RN, BSN: Executive Administrator for the Thro Company, a nursing home company based in Mankato, MN. She has over 18 years experience in long-term care as a DON, Resident Services Director and Administrator.

James Cooper, Pharm.PhD.: Consultant pharmacist to a 167-bed hospital-affiliated nursing home and 40-patient day care and senior citizen center affiliated with the University of Georgia College of Pharmacy, Athens.

Panel moderator: Laura Bruck, Managing Editor, NURSING HOMES

What are some of the issues that have tended to undermine support and communication among professional nursing home staff?

Ditzler: We all bring our own professional viewpoint to our work, based on our experience and knowledge base. As nurses, we tend to be rather tunneled: we want to be told how to perform a task and then be allowed to accomplish it. Physicians sometimes become short-tempered with us -- and rightfully so -- when we don't have the answers they need, and especially when we claim those answers are someone else's responsibility.

Sabella: But I've found that some of those types of issues have been resolved with the team meetings mandated by OBRA. Many of the problems that were once swept under the rug are being brought out in these formats as part of quality assurance.

Dr. Neufeld: From a physician's viewpoint, one of the things that bothers me is that doctors haven't yet become active members of the nursing home community. At the American Medical Directors Association meeting in San Diego, I became aware that most medical directors spend only 5 to 10 hours per week in the nursing home, probably because that's not where their salary or their interest lies. As a full-tune medical director, I have a somewhat different perspective. As we admit more subacute patients and become more conscious of the team approach, the primary care doctor and the medical director will need to become more involved with QA and assessment. And I think that's what's been lacking to some extent.

Ditzler: Would you also agree that the medical director's role has been rather ill-developed? That may cause some uncertainty about what's needed from them in the long-term care setting.

Dr. Neufeld: I think there's some truth to that. The medical director is often caught between an administrative and primary care role and sometimes fails to develop a good rapport with the administrator or DON. I agree that involving physicians in QA brings them into the administrative area where the professional staff can work together on standard of care issues.

Sabella: We certainly find that to be true. Maybe we're lucky because our medical director has known us and our capabilities for a longtime. We feel very comfortable sitting and talking with him, and he feels equally comfortable with his role here. And I think that level of involvement is critical.

Dr. Cooper: I think the important issue is what opportunities exist for improved communication. From my perspective, we're seeing prescribing-related problems influencing the need for nursing home admissions in over half the cases in our studies. And, every second or third month thereafter, almost every patient has a medication-related problem that requires good interprofessional communication and team meetings to resolve, whether they be medication errors, significant adverse reactions or just the need for improved pharmacotherapeutic planning.

How can the professional staff begin to resolve these problems?

Dr. Cooper: I believe intensive drug regimen review is the key. It's traditionally fallen on the consultant pharmacist's shoulders, but we need a concerted team effort by the medical director, attending physicians, DON and consultant and provider pharmacist to provide some unifying concepts, such as universal problem lists and progress notes. Because we may not all be at the nursing home at one time, we should at least have a centralized record of our activities and a way to unify our communication to address problems and improve quality of care.

Dr. Neufeld: But don't you have quarterly or semi-annual meetings scheduled with the physicians as part of the QA process?

Dr. Cooper: We do, but in real life, it's practically impossible to get everyone together at the same time. I have to track down individuals and try to work closely with the DON. I really believe that nursing homes are aptly named because the nurses are the people who truly care for the residents.

Dr. Neufeld: I think administrators can play a key role in bringing people together if they make doing so a high priority.

Sabella: I think that's the key to QA. All our staff is part of QA: nursing, the medical director, pharmacist, infection control, dietary, social services, plus the auxilliary staff. This is where they air their concerns and we try our best to problem-solve. But it's time consuming and requires the type of people who are willing to make that effort.

How can you help to bring the medical director and other physicians "into the fold?"

Dr. Neufeld: I agree that time is a problem for doctors, including those who serve as medical directors. But if you check their availability well in advance and meet for breakfast or lunch, when the doctor has to eat anyway, you may have better luck. If they still don't make it, find out what incentives would encourage their participation.

Ditzler: I agree that time management is an issue. But I really believe that the collaborative effort is the responsibility of each professional. The problem stems from our inability to teach each person that they are responsible for their own relationships. Whether it's a pharmaceutical problem or a disagreement between administration and dietary, we need to teach healthy relationships based on mutual respect, functional trust and open communication.

Sabella: And you do that by physically sitting them down together and making them understand the importance of being there and providing input. If we can't work together towards a common goal, we shouldn't be working together at all.

Ditzler: I think that can be taught; it's a learned concept. There's been too much blaming and back-biting. If we have a problem with a nursing assistant, we need to go directly to that nursing assistant, rather than going under, over and around that person. We need to remember that at the heart of our ability to serve our clients is our ability to handle our own healthy relationships.

How will the move toward subacute care change your professional roles and relationships in the nursing home?

Dr. Cooper: Many of our patients fall into swing-bed subacute categories. In the last two decades, I've been seeing older patients with an average of 10 to 12 active problems rather than the five or six we were seeing on problem lists 10 or 15 years ago. So it appears we need a very strong team effort to deal with sicker patients with more problems and to do so with fewer health care dollars. That's where communication becomes so vital; having to do more with less.

Dr. Neufeld: I have a number of concerns about subacute care. I feel that the nursing home patient is becoming one of the most difficult to treat, and that education of the physician needs to begin before long-term placement of that physician's patients. Even today, medical and nursing schools don't seem to place enough emphasis on geriatrics and nursing home patients. Hospitals are geared toward short stay and acute intervention, and they don't have to deal with many of the problems that we do once residents are admitted. The result is that all of a sudden we have a very debilitated and often demented patient with complex diseases on our hands, and a subacute intervention that requires an interdisciplinary approach to care.

Ditzler: I couldn't agree more. I'm concerned that the financial changes and all the discussion of subacute care is virtually forcing nursing homes into the market without the proper education and preparation. And traditionally, we have chronically low numbers of nursing hours -- both service hours and training hours -- for our residents. Would you agree?

Dr. Neufeld: I think that's indeed part of it. We don't have enough clinical educators coming into the nursing home and I don't think clinical training efforts are sufficiently supported in the industry.

Ditzler: Exactly. And in addition, we have an historically poor representation of professional RNs in the nursing home. We now have a Federal law -- OBRA -- that requires licensed professionals on the premises 24 hours a day and an RN for at least eight hours each day. And now the types of patients Dr. Neufeld is describing are going to be the responsibility of our nursing assistants and LPNs who are practically running our homes from 3:00 pm to 7:00 the next morning. I have grave concerns about this.

Sabella: Once again, I think staff education is the key. Almost all our nurses are IV-certified; that's one of my mandates. A number of them have been through a stringent program for our special care unit. Our 54-bed SCU is overseen by the Alzheimer Research Demonstration Project, which provides 60 hours of training to all staff. The result is that many of our residents have been titrated off many of the antipsychotic drugs, most are no longer incontinent and they're ambulating and participating in structured activities. The SCU program has been so successful in its approach to care that we've extended it to the rest of the facility staff in a sensitivity program. And when we look at outcomes, I'm almost certain we'll find that it's cost-effective. It has already increased our private census and has done wonders for morale.

Ditzler: I think we'd all agree on the need for increased reimbursement, as well as the staff education that Ms. Sabella describes, the added hours, the staffing changes; all are going to require some dollars and, unfortunately, they're probably not going to come soon enough.

Dr. Cooper: I've heard projections that over 90% of patients are in privately owned nursing homes, yet around 60% of patients are paid for from public support. And therein lies the rub; the discrepancy between the bottom line and what we need to eak out to provide good patient care. Is it less expensive to pay for a medication error-related hospital admission than a sound distribution system with dosage accountability? These kinds of questions trouble me when we look at the way the system is populated and paid for. This is a glaring problem with the way we finance health care in this country.

What types of changes are needed to begin to solve some of those problems?

Sabella: Let's be honest: This is a business. I'm fortunate to be working with a company that cares about the quality of life and care of its residents. But not everyone in the field is part of a company that cares. The nursing home population basically consists of Medicaid patients because families have been educated about the Medicaid system and its acceptance requirements or do not have sufficient funds to cover the costs of care. So the secret is surviving financially with what we have and doing what needs to be done with staff, families and outside forces. Changes, if any, will come from us, in time.

Dr. Neufeld: I think there are two things that need to happen: Consumers need to be educated and to become part of the process. I think they often have unrealistic expectations about what the nursing home can accomplish, and families are too often held at a distance for a variety of reasons. I also feel that the nursing home image has to change. If we're going to provide subacute care, we have to be viewed as caring providers of quality care, rather than places of last resort. It's always the negative image of nursing homes that's portrayed in the media: taking advantage of old, debilitated people. The positives are never mentioned.

How should we go about changing that image?

Dr. Neufeld: Again, I think it has to be part of an overall education process. And the state surveyor system needs to evolve a bit differently as well -- providing some praise and encouragement, even an educational and networking framework, rather than simply coming in, finding fault and enforcing the rules. I find that there's a real isolation among nursing homes, a lack of networking, idea exchange and joint problem-solving among them.

Ditzler: We've found that inviting families in to care conferences has been a great vehicle for educating consumers -- sharing assessments, evaluations and treatment plans and getting their input about how we can better care for their loved ones. In the process, we're able to articulate and identify the professional services we provide. Also, role modeling our team approach and collaboration is going to strengthen the nursing home's identity.

Dr. Cooper: We see upwards of 20 to 30% of our patients' families coming in to our quarterly meetings. We also have a "family meditation night," where we answer medication-related questions or forward them to attending physicians for resolution or further discussion. With the plethora of drugs on the market today, some of which may not provide any distinct therapeutic advantage, it's important that we address family concerns about why we may not be trying the "latest and greatest." They simply don't understand the way health care is financed and the way the nursing home operates.

Sabella: We have separate family meetings for each of our four units. We inform families of this at the time of admission and send out follow-up letters, and we get a magnificent response. The meetings are usually attended by nursing, social services, the ADRP Project Director, if involved, one of the unit's residents, myself (when necessary), and at times a member of the Alliance for Better Nursing Care, a patient advocacy group. We hope to arrange for our medical director to attend in the near future.

Ditzler: I think part of our mistake as administrators and directors of nursing is not inviting medical directors to these types of functions. We need to apply the rule, "ask for what you need and you'll increase the chances of getting it." I'm sure many of the pharmacists and medical directors would be happy to take an hour to attend such a meeting. We just assume that they're too busy to come and simply don't invite them.

Dr. Neufeld: Once again, physicians need to play a more ongoing role in the assessment, communication and QA function. Once they realize they're welcome--but especially if they have patients in the facility who require more medical input -- the system is going to change. All of this has to be supported by administrators and, certainly, the reimbursement mechanism has to be there. I feel that the trend in medicine is going to be: out of the hospital sooner and into the community. And I think the role of the nursing home is going to be changing in line with this, assuming that there is a more active interface between community-based medical providers and the hospital.

Sabella: At least here in Rhode Island, I can't imagine how patients could be discharged from the hospital any sooner than they already are. Most of the time, we're lucky if they're in the hospital 24 to 48 hours after placement of a G-tube.

Dr. Cooper: We had a similar situation here. The total per diem allowance for a swing-bed stay was exceeded by drug costs alone within the first 24 hours in over 90% of patients. As a result, we dropped our swing-bed concept. There's simply not a mechanism that adequately addresses transition to subacute care.

Dr. Neufeld: The government is certainly addressing the issue of drug costs. But the average patient is receiving multiple doses of a number of drugs, so we're tying up 10 or 12 drug transfers per patient per day. This is a real problem, and many of these patients could be on fewer drugs.

There has been a great deal of discussion of problems related to medical therapy and residents being over-medicated. Do you have any potential solutions to these problems?

Sabella: We support drug titration in reducing medication use in general. Our patients in the special care units are no longer over-medicated. It took a great deal of work and it didn't happen overnight, but it can work.

Dr. Neufeld: Doctors need to be aware that geriatric patients can do with much less medication. We just completed a drug holiday on haloperidol. Not only is this drug the most frequently prescribed for the agitated patient, but it has a very long half-life as well. We were able to eliminate its use two days a week, and 60 to 70% of patients did equally well. Once the patient is stable for a number of weeks, the drug doesn't need to be given more than once daily. When we "blinded" the nurses, doctors and families, they couldn't tell whether the residents were on the holiday or not.

Any further reflections on the collaborative effort needed to improve residents' quality of life?

Ditzler: I'd like to comment on the need to challenge some of the archaic medical standards we employ and what that challenge will do to our professional relationships. For example, we're all looking at different ways to feed residents: regular geriatric diet versus therapeutic diet. Dietary and nursing have traditionally held different views on the subject. Some of these new ideas butt up against all that we've been taught and changing some of these standards is going to infringe on some professional territory.

Dr. Neufeld: It's important to remember that if you're going to question standards and values, you need research to support any changes.

Dr. Cooper: Using the nutritional theme as an example, I can tell you from our research that virtually every nursing home resident has some degree of malnutrition. There's a paradox here that we've never really addressed. We make decisions to spend several hundred dollars a month on medications, but we don't aggressively pursue nutritional therapy for that patient. It seems that it's easier to prescribe a drug than it is to make a conscious decision to enhance nutritional status.

Dr. Neufeld: We could all use some additional education in that area. I don't think I had one class on nutrition in medical school.

Concerning the bottom line, what sort of support can other professionals provide administration in gaining the financial support needed to provide state-of-the-art chronic care?

Sabella: That's something that's going to have to come from powers higher than the internal staff unless we can band together facility-to-facility. As an example, in Rhode Island, we're all going to the State House to celebrate National Nursing Homes Week and take advantage of the opportunity to be heard by the powers-that-be. We've invited our representatives and senators to join us there to become reacquainted with us and to learn about what it is that we do.

Dr. Cooper: We need to take a close look at clinical outcomes. For instance, by treating problems aggressively in a chronic care setting, can we actually decrease the frequency of hospitalizations? If chronic care involves a continuum from the community to the nursing home, the long-term care facility should be more than just an "end place," but a place of rehabilitation as well. I've worked with nursing homes where 40% of patients were rehabilitated and sent back to the community every year. But I don't believe we have the funding mandate to produce results such as these on a large scale, even though, in my opinion, we don't devote enough attention to the interventions that keep chronically ill people from becoming acute patients.

Dr. Neufeld: I think we'd all agree that patient assessment involves a great deal of work by a large number of people: examinations, reviewing multisystem problems, and so forth. This may be the rationale we need for all of us to get together on a regular basis and try to improve collaboration.

Are you optimistic about this?

Sabella: I don't intend to give up. I've been in long-term care for 26 years. I still care, and I won't stop trying.

Ditzler: I'd like to add a note of optimism as well. Consulting with nursing homes all over the country has shown me that we have some very caring, creative people who have been able to do remarkable things with limited funding. That gives me great hope that, as reimbursement issues progress and health care reform affects our business, we'll still have valuable, committed people making unique contributions and doing the job.

Dr. Neufeld: I'm also optimistic because the move of some health care out of the hospital and into the nursing home should set us up to be the leaders in geriatric care. It's just a matter of putting aside petty differences and accepting that challenge, not just for profit, but for the betterment of our patients.

Dr. Cooper: I couldn't agree more. And I want to reiterate the importance of health care financing reform for long-term care. It's a very cost-effective modality of care that everyone is entitled to. Working together to improve overall care, to keep patients as healthy as possible with as much quality of life as possible is something I think we can accomplish, beginning with discussions like the one we've had today.