Paving the road to subacute care: professional liability issues.

The introduction of subacute care opens a new and promising chapter in the evolution of the long-term care industry. For this story to have a happy ending, however, providers will have to successfully deal with a host of new professional liability management issues.

Long-term care facilities have shown that they can be a cost-effective option for providing medical services such as ventilator and respiratory care, intravenous therapy and wound care for individuals requiring inpatient medical supervision. This evolution of long-term into subacute care has been driven by the need for a level of care between costly hospital-based services and that of the minimally supervised home health services. In this respect, the long-term care industry could play an important role in health care reform if it reduces the total cost of patient treatment without compromising the quality of patient care. Subacute care also promises to provide a new source of revenue and potentially higher profit margins for the long-term care industry. The current reimbursement structure establishes subacute care as an attractive financial market for most long-term care providers. However, if nursing homes fail to pay close attention to professional liability risk management issues, the road from custodial to subacute care could be a rocky one, the quality of patient care could suffer, and those hoped-for profits could quickly evaporate.

Incident Reporting and Claims Management

In the past, malpractice risk was insignificant for most long-term care providers because there were few professional liability risks associated with custodial care. With the introduction of subacute care, however, there is every reason to expect that nursing homes could experience some of the same claims activity that hospitals have faced over the years in providing acute and subacute care.

The long-term care industry should analyze the claims history and loss prevention strategies of hospitals. Significant issues to be evaluated are the incident reporting and claims administration procedures. Minimizing professional liability risks is largely dependent upon the facility's ability to identify exposures, investigate incidents or evaluate opportunities to improve care and manage claims. In addition, providers will need to evaluate the ability of their present legal counsel to provide legal advice and litigation services in the area of professional liability. Attorneys who specialize in health care law and medical malpractice defense will better serve the needs of the subacute care facility than will those attorneys who do not practice in this area.

Employment and Continuing Staff Education

Subacute care will require a more diverse staff of health care providers with a different set of clinical skills than those traditionally required in long-term care facilities. Nurses will need a broader base of knowledge regarding disease processes, medications and medical technology. The level of care will shift from meeting the health maintenance, psycho-social, and custodial needs of residents to an increased level of medical monitoring and care for a variety of medical patients. With this diversity will come higher salary demands as nursing homes compete with hospitals and other providers for qualified personnel.

Ensuring the competency of clinical staff is a key risk management strategy to avoid or reduce the possibility of patient injury. In the subacute environment, the employment and continuing education of qualified personnel will be critical. Facilities should maintain documentation verifying the clinical skills and subsequent education for each health care provider for the duration of their employment in order to demonstrate continuing proficiency in his or her practice area.

Medical Staff Considerations

Providing subacute care will change the composition of the medical staff with the need for increased medical supervision of patients with varying diseases and illnesses. Medical staff by-laws, rules and regulations must reflect these changes. In addition, the credentialing activities of the facility must be expanded to include those medical specialties not previously required for medical supervision of the traditional long-term care resident: internal medicine, surgery, pulmonology, neurology, etc.

The increased frequency of medical intervention for the subacute patient will also require enlarging the scope of medical start quality review activities. Clinical monitoring and evaluation indicators for the newly added specialties must be incorporated into the current medical staff QA/QI program.

Documentation Practices

One of the first considerations long-term care providers should address is medical record documentation practices to accommodate the additional record keeping requirements for the delivery of subacute care. Different clinical data will be documented as a result of increased patient monitoring and evaluation.

In terms of frequency, documentation will be varied and more frequent than the daily or weekly charting typically practiced. The typical nursing home today uses a narrative charting format for a large percentage of notes, as hospitals did a decade or more ago. With subacute care, long-term care facilities will need to move in the same direction hospitals have in utilizing more check-lists and forms, which are quicker and also ensure that established standards of care are addressed and properly documented.

Infection Control

Infection control efforts related to traditional custodial care have generally focused on communicable diseases and decubitus ulcers that commonly threaten the geriatric or immobilized resident. Infection control guidelines must be established for the treatment of subacute patients whether they are ventilator-dependent, receiving intravenous antibiotic treatments or recovering from surgical procedures. A quality review mechanism in this area is important to ensure compliance with appropriate infection control policies and procedures.

Design of Patient Care/Resident Units

In the traditional nursing home setting, residents are not restricted to their rooms and are permitted to enter other residents' rooms and share common areas for social activities and meals. This mobility and degree of socialization may not be possible for some subacute care patients due to the obvious privacy and infection control issues confronting the sicker patients. Although isolating or segregating certain categories of residents is discouraged in long-term care, physical design changes to the facility may include locating subacute patient rooms near the nursing stations to facilitate monitoring and more frequent observation.

Patient Satisfaction

Long-term care providers are in jeopardy of losing one advantage they have held over their acute care counterparts: the ability to establish favorable, long-term relationships with residents and their families. Unlike most residents, for whom the facility is an indefinite home, subacute care patients may only be in the facility for a limited period of time.

Expectations of the subacute patient about service and staffing will also be different from those of the long-term care resident. Studies have shown that not meeting expectations or treating individuals in a disrespectful or non-caring manner is more likely to result in patient complaints and allegations of negligence than is dissatisfaction with poor outcomes.

Requirements by managed care organizations for long-term care facilities to provide data which indicate patient satisfaction with services come on the heels of OBRA regulations for long-term care. These regulations emphasize the need for timely resolution of patient complaints to enhance the relationship between the facility and its residents.

Assuring patient satisfaction has long been recognized as a key risk management strategy in avoiding claims and controlling losses. In addition, the ability to satisfy patients, residents, and families will be a substantial factor in securing and maintaining managed care contracts.

Conclusions

The challenges in offering subacute care services in long-term care facilities are not insurmountable. If subacute care can be offered at a lower cost than care rendered in a typical acute care hospital without sacrificing the quality of patient care, then long-term care facilities could become the preferred and more appropriate setting for the delivery of subacute care.

Implications for change and the corresponding liability exposures should not prevent or discourage the long-term care industry from entering this new area of health care delivery. The industry has the advantage of learning from the experiences of acute care providers because similar areas of risk will be more easily identified and successful loss prevention strategies can be duplicated where appropriate. Each provider should carefully evaluate the effectiveness of their current risk management program and take appropriate steps to position the facility to provide subacute care in the most cost-effective manner, while remaining committed to delivering safe, quality care.

Sherrie W. Dewease, RN, MS, JD, is Senior Vice President of Willis Coroon's Health Care Concepts division, Nashville, TN. Her 15 years of health care experience includes eight years of clinical practice in obstetrics and adult critical care. Ms. Dewease is licensed to practice both law and nursing in Alabama and Mississippi. She was named Public Health Nurse of the Year by the Mississippi Nurse's Association.