Progress report on a "continuum of care" partnership.

An experiment in linking up long-term care services is achieving success

Nearly three years ago when we wrote in NURSING HOMES of our dream to provide a broad range of long-term care services, including nursing home care, to older adults in a retirement community setting, we painted in broad strokes: our ideals, our standards, and our mission ("Academic-Corporate Partnering to Improve Long-term Care," Nursing Homes, July/August, 1991). Since that time, we have learned much about developing and coordinating such a continuum, and a long-term care program of substance has been built. Indeed, the partnership between the University of Washington School of Nursing and ERA Care, Inc., owners and operators of Ida Culver House Broadview, is thriving. Here are some of the lessons we learned along the way.

From Vision to Details

The early stages of shaping the organization were truly a collaborative effort, with weekly meetings among the partners and the new administrative staff. This period of intensive work established a solid sense of the vision of the partners and prepared the leaders of the organization to carry out the goals the partners created.

The vision became more of a reality when the staff grappled with developing a mission statement that articulated their values. Through discussion and reflection, we agreed that our mission is "to create a caring and enriching community through a partnership of residents, families, staff, and students, who all work together to promote the health and well-being of its members." We agreed that our values are teamwork, recognition of the individuality of our residents and staff, optimizing environmental support of health and well-being, and striving for excellence in our care and services.

Creating Systems and Structure

Ida Culver House Broadview has almost 400 residents in three levels of care (Independent Living, Assisted Living, and skilled nursing in the Nursing Care Center) and over 200 employees. In this type of setting, obviously, effective communication among all participants is essential for smooth functioning and high quality care delivery. To optimize staff communication, we provided staffers with opportunities for discussion and input, involved them in working committees and developed mechanisms for exchange of information.

The backgrounds and experiences of the staff varied considerably and we needed to start from a common ground. We offered an eight-week course to all our coordinators and managers on improving their leadership and supervisory skills and building the team. Our RN staff participated in a leadership series that emphasized their role as "Partners in Care" (PIC) team leaders who direct the care of residents in collaboration with nursing assistants, therapists, physicians, and social service, nutritional and activity staff. With this strong, committed group of leaders, we were prepared to evaluate the structure and functions we initially developed, improve and refine our care delivery, and fine-tune our systems.

This did not proceed smoothly at first. It will come as no surprise to the readers of NURSING HOMES that the complexity of our organization and the regulations we had to observe -- employment practices, environmental safety, licensure for Board and Care and Skilled Nursing, for example -- took a degree of time and energy that detracted from our central mission. Nevertheless, we forged ahead.

Evaluating Quality

During the early phases of our development, quality assessment was at its most basic: were the right interventions occurring at the right time for the right people? As we worked out our procedures and communication systems, service and care delivery became more consistent and reliable. We were able to develop other indicators of the quality of our care, such as resident, family, and staff satisfaction and measurable outcomes of our programs, such as rehabilitation services. Our program outcomes include utilization data and achievement of care objectives, and with our academic partners we are continuing to refine these.

"Customer satisfaction" is evaluated in a number of ways, using surveys, regular meetings with residents, family and staff, and through a suggestion box. These mechanisms have yielded a number of ideas that have been implemented, ranging from environmental modifications, to procedural refinements, to new ways of communicating. For example, residents and families manifested considerable concern about earthquake preparedness. We developed a disaster awareness program for staff, complete with educational sessions and drills.

Developing the Continuum

Our community filled quickly and we have a consistently high level of occupancy. Within such a varied community, there are a number of subgroups who move to Ida Culver House Broadview, each with different goals in mind. Some are seeking a permanent home and desire the option of progressing through all levels of care as needed. Others are admitted for short-term stays and plan to be discharged back to their own homes. Depending on the needs of the resident, the plan of care and expected outcomes vary.

We have seen considerable movement within the community as Independent Living residents have experienced acute illnesses or injuries and have needed skilled nursing care or personal care assistance. One difficulty has been that residents in Independent Living often believe that they can take themselves directly to the Nursing Care Center for needed services, much as they would in a continuing care retirement community. Our organization is not set up in this way; each facility is separately licensed, and formal admission is required. This requires considerable education of the residents.

Both the Nursing Care Center and the Assisted Living program can accommodate short-term care with supportive therapies (occupational, physical, and speech) to return the resident to the lightest level of care possible. Residents who have initially come to the Nursing Care Center from the general community have also been discharged to Assisted or Independent Living. As some residents have become more functionally or cognitively impaired, they have moved to Assisted Living or the Nursing Care Center. Family health care is a central focus, with a number of spouses or siblings receiving care in different areas and a respite program in Assisted Living.

As for other services, the Medicare Rehabilitation Program has achieved impressive results, with the majority of enrollees being discharged to a lighter level of care. The Cognitive Impairment Program, focusing on environmental and behavioral management in a Special Care Unit setting, has resulted in a marked reduction in the use of chemical and physical restraints among residents who were admitted from other facilities that emphasized these approaches.

At the hub of all these services, and enabling us to effectively coordinate them, is the Wellness Clinic. All transfers from level to level go through the Wellness Clinic, which serves in a case management capacity. It has over 1,200 nursing consultation visits per year, and active direct care services including foot care, laboratory services, podiatry, transportation, massage therapy, and dentistry. Its health promotion efforts have included an Annual Health Fair, with informational booths, a health lecture series, flu immunization, and group activities, such as Caregiver Support and Tai Chi.

A Look to the Future

Taking advantage of our academic affiliation, our next efforts will focus on formal program evaluation, including solidly-based indicators of both quality and cost. Several research projects conducted by faculty and students of the UW School of Nursing at Ida Culver House Broadview have examined quality of life, clinical interventions, and organizational characteristics. Further research of this type is planned and will enhance our program evaluation.

Meanwhile, we have come to the realization that we providers in long-term care can make a difference in the quality of life of many older adults, and that our multi-disciplinary interventions can improve functional ability, socialization, and management of chronic illnesses. In this time of health care reform, it is crucial that we are accountable for the quality and cost of our programs, and that we are able to articulate the contributions of independent living, assisted living, skilled nursing, and wellness programs to the spectrum of health care services. We believe that we have laid a firm foundation for doing just that.

Heather M. Young, PhD, ARNP, is a Research Assistant Professor in the Department of Community Health Care Systems at the University of Washington and is Executive Director of Ida Culver House Broadview. Sue T. Hegyvary, PhD, FAAN, is the Dean of the University of Washington School of Nursing and Professor in the Department of Community Health Care Systems