Successfully implementing divergent specialized programs in a SNF. (Feature Article).

In 1998, the Gurwin Jewish Geriatric Center, in Commack, New York, was a 300-bed, not-for-profit skilled nursing facility (SNF) with a substantial admission waiting list. A Certificate of Need was approved by the New York State Department of Health for Gurwin to build a 135,000-square-foot addition to include 160 beds, a new and expanded adult day care center, and an outpatient health services suite. Construction of this new Harry and Jeanette Weinberg Pavilion was completed in July 1999. Given the facility's exceptional double and triple board-certified, full-time medical staff; comprehensive on-site diagnostic and multispecialty clinic suite; and in-house pharmacy equipped with a laminar flow hood, the facility already routinely cared for medically complex subacute and long-term residents requiring intravenous antibiotics, tracheostomies, hospice, and CAPD. Anticipating a significant increase in such higher acuity admissions, a wall-mounted oxygen and suction system was installed at each of the 80 beds with in the two adjacent nursing units on the upper floor of the new pavilion. Prior to the 160-bed expansion, the prevalence of mild-to-severe dementia within the facility was conservatively more than 70%. An average daily census of 10 in 1998, currently 20, short-term subacute rehabilitation residents were clustered on one nursing unit.

The composition of the first of the new 40-bed units was primarily a mix of elective resident transfers from semiprivate and private rooms, and several new admissions. Rather than designate a dementia unit which, perhaps, might benefit 40 of more than 200 such residents, it was decided to use the second unit to accommodate alert, oriented, and socially interactive residents who were situated randomly in semiprivate and private rooms within the original facility. Also, plans for a secured, custom-designed and comprehensive 19-bed dementia (Enriched Pathways [TM]) unit were concurrently being finalized within a new 200-apartment assisted living building to be situated on our campus. We believed that this more independent environment would more suitably meet the needs of individuals requiring such care.

The AOS Unit

The pavilion's second 40-bed unit accommodates alert, oriented, and socially interactive (AOS) residents who were selectively and voluntarily transferred there subsequent to a series of resident and family informational meetings, Resident Council discussions, individual tours, and a lottery process for the unit's four private rooms. The departments of Administration, Nursing, Social Work, Medicine, Therapeutic Recreation, Rehabilitation, and Food Services unanimously believed that the immediate and long-term quality-of-life benefits would be substantial for those residents who were assessed as appropriate and able to benefit from socialization. The second of the new 40-bed units was selected for this contingent rather than the first, since we projected that there was a sufficient number of appropriate indigenous residents to fill it. The local community would have perceived precluding new admissions to the first unit of our building expansion as self-serving rather than community responsive. They were well aw are of and eagerly anticipated the opening of our new pavilion, given our extensive waiting list for several years prior to its opening. The third and fourth 40-bed units, which have the wall oxygen and suction system, were designed primarily for our respiratory care program, which is described later in this article.

A series of in-services were held to further prepare the unit's staff, the majority of whom had requested transfers to this unit, for the challenges of a now aggregated and quite demanding resident cohort. During and subsequent to the four-week fill-up of the AOS unit with residents who requested and were approved via a multidisciplinary assessment for transfer, a variety of tailored unit-based therapeutic recreation programs were developed, including computer classes featuring individual instruction. The vast majority of these residents also continued to participate actively in the facility's comprehensive array of centralized morning, afternoon, and evening activities, and outside trips. Our facility's regular meal tray service was changed to a unit-based restaurant style, to provide a more independent dining room atmosphere.

Several AOS residents were current and past officers of our active and vibrant Resident Council, who had negative demented-roommate experiences in the past. Initial and renewed friendships and/or significant- other relationships on the unit soon evolved. Early in the implementation phase, it was obvious that nearly all of the residents were significantly happier in their new environment, participating more actively in programs, enjoying companionship and special interests throughout the days and evenings, and asserting their needs and desires with greater individual and collective vigor and persistence. AOS resident food and activity preferences continue to flourish. "Happiness" is, of course, a relative term. Unit and managerial staff at all levels in each discipline face the daily challenge of meeting the plethora of AOS residents' assertive and insistent preferences to the best of their ability and often to the test of their extraordinary patience. The nurses, CNAs and unit receptionist, in particular, des erve exceptional praise for their daily boundless "customer service" responsiveness and compassion.

As stated earlier, the AOS unit was intended for residents who were not only assessed as alert and oriented, but were projected to benefit from the unit's milieu, as well. From the unit's planning stages through today, we have had to respond to several unrealistic family members of residents on other units who earnestly believe that their loved ones are appropriate for the AOS unit. For the most part, such requests were founded in extraordinary denial .of their loved ones' dementia. Since the unit opened, we have had between five and eight appropriate AOS residents on our in-house transfer request list. We have aggregated a cohort of six such residents on one of our original nursing units, closest to our main lounge and popular lobby area, so that at least the benefits of their more frequent mutual socialization has been achieved. The unit has not had any new admissions. Although at least ten of the originalAOS unit's residents have had significant physical deterioration, primarily from their pre-existing ill nesses, only three have expired to date.

In 2001, we revised the admission criteria for the AOS unit to include a minimental status exam (MMSE) score of 25 or above, regular group activities participation, and no unpredictable, nonphysical illness-related disturbing behaviors. Discharge (transfer out) criteria now include any two of the following: an MMSE of below 20, minimal weekly activities participation, and ongoing unpredictable disturbing behaviors. The multidisciplinary team also had a series of meetings with all ACS unit residents in December 2001 to address several residents' verbal abuse of staff, particularly in the dining room and while waiting for medication administration, both of which subsequently improved significantly. Unintentionally, an "elitist" perception of this unit, by AOS residents and other units' residents, was also addressed with modest success.

We had only one, mutually desirable resident transfer off the AOS unit, during the first month of implementation. It, therefore, appears that we have been successful in selecting and maintaining an appropriate AOS population. However, subsequent to a recent series of care-planning strategies with two residents with their family's participation and acceptance, and based on the aforementioned discharge criteria, we anticipate having to transfer these no-longer-appropriate residents to other units. Social workers identified possible roommates on other units, to minimize resident readjustment difficulties and their possible perception of "failure." Because the facility operates at full census on a daily basis, planning for optional roommates for such residents is a challenge, but essential for maintaining their dignity and overall satisfaction. Alternatively, residents who can no longer benefit from the ACS unit due to significant cognitive and/or physical decline will likely become more isolated, frustrated and disheartened if they remain. AOS unit staff have shown an understandable tendency to "adopt" their residents, however. AOS staff have had difficulty highlighting inappropriate behaviors which might substantiate the transfer of no-longer-AOS-appropriate residents to other units.

Ventilator-Dependent Unit

In 1998, subsequent to an in-depth financial and operational feasibility study, the Gurwin Center submitted an additional Certificate of Need to establish a 28-bed certified ventilator-dependent program to be situated within the fourth 40-bed unit in the Harry and Jeanette Weinberg Pavilion. The administrator, medical, nursing and social work directors visited two well-established local SNF-based vent units, and attended their multidisciplinary care planning and related meetings. Based on these experiences and area hospital discharge data, we projected vent-resident profiles to include primarily individuals with COPD and other lung diseases, post-CVAs, and a few progressive neuromuscular disease and trauma victims. The latter two groups were expected to have considerably more than the average scope and intensity of resident and family psychological issues. We also expected a proportion of approximately 10 to 25% weanable patients. The average age was projected to be significantly younger than our existing fac ility age of 84.

Environmentally, the 40-bed unit housing the ventilator-dependent program already had the appropriate number of private rooms to meet New York State Department of Health infection-control requirements, sufficient utility, equipment storage, and two deluxe shower rooms. Each "biaxial" semiprivate room, i.e., similar to adjacent private rooms without a separation wall and second bathroom, also afforded optimal resident individual space, custom furniture, windows, and sconce lighting.

Programmatically, our first major task was to recruit a full-time, experienced, and outstanding director of respiratory therapy, which we accomplished through an exhaustive search process. We then embarked upon the selection of ventilator equipment that would meet our technical and functional specifications. We chose a lease program, in order to keep pace with technologic advancements, which included an option for alternate ventilators that might be required in unusual clinical situations. We selected a ventilator alarm system that was accommodated by our nurse-call system, but audibly distinguishable. Within a year and a half of opening the unit, we replaced this relatively inexpensive system with a more sophisticated, independent ventilator alarm system which offered additional features and other advantages.

We initially employed two part-time pulmonologists for this program, who were subsequently replaced by a contract with a group of senior-level pulmonologists, including a chief, providing halftime on site, and 7-day/24-hour on-call coverage. Additional respiratory therapy, nursing, and ancillary staff were hired in tandem with the vent unit's resident census growth. At full census (28), the director of respiratory therapy and two fulltime respiratory therapists are on duty on the day shift, two on the evening shift, and at least one on the night shift. In-services and related competencies for all unit clinical staff are completed on an ongoing basis.

Two significantly underestimated issues were the presence of multiple and varied antibiotic-resistant organisms in most vent admissions, from numerous area hospitals, and extraordinary resident and family psychosocial problems. The latter ranged from coping with sudden and progressive neuromuscular diseases in younger residents, through terminal resident ventilator weaning situations. The conservative matching of vent-resident roommates having the same (or absence of) antibiotic-resistant organisms, considerably decelerated our ability to admit many vent applicants. Our 11-month vent program fill-up would have taken less than six months if we did not have this almost-daily obstacle to contend with. Medical directors of longstanding SNF vent programs in the New York area have also experienced this increasing problem, particularly in the past two years. With respect to the multitude of psychosocial issues, frequent social work interventions, psychological counseling, and support groups for vent residents and th eir families were initiated and have been well received on an ongoing basis.

Since program implementation, we received several ALS (amyotrophic lateral sclerosis) ventilator-dependent applicants and reached a census of seven concurrent ALS vent residents. According to ALS Association regional representatives, this is the largest cohort of ALS vent residents in a U.S. skilled nursing facility. One such resident, a local college administrator who communicates exclusively via a minimal-eye-movement-activated laptop computer, was the keynote speaker in a regional ALS conference hosted by the Gurwin Center last year. Gurwin garnered very complimentary newspaper and television coverage of our ALS, as well as other vent residents' quality of life in the facility.

Speech language therapy for vent residents has been extensive, including, multiple bedside and in-house video fluoroscopy swallowing evaluations (and preparation of related individualized diet consistencies), assistive devices ranging from low-tech communication boards to sophisticated laptop computer devices, and an array of tracheostomy "speaking" valves. Vent-resident speech language therapy staffing needs exceed the unit's total physical and occupational therapy staffing needs.

We have weaned residents off ventilators, and in some instances been successful in discharging patients with and without ventilators with home care services. Our home care staff have participated in vent unit care-planning meetings and have acquired additional knowledge and experience in caring for patients who have required ventilators, as well as tracheostomies. The overwhelming number of physiologically nonweanable residents suffering from progressive neuromuscular diseases, including ALS, MS, and Guillain-Barre, has been a disappointment to our professional staff. However, in addition to advanced neuromuscular diseases, many of our vent residents have multiple and complex cardiac and other medical problems, which have provided extensive clinical challenges. We have periodically refined our vent-applicant clinical-approval criteria to preclude ICU level-of-care requirements.

Our certified therapeutic recreation specialists provide a vast array of daily bedside one-to-one and unit-based group activities for our ventilator-dependent residents. Many other bedside ancillary services have been introduced on the vent unit, including beauty/barber and dental services. Approximately one-fifth of the vent residents have enjoyed half-day and full-day therapeutic leaves of absence to attend family, social, formal, and recreational events, such as Yankees games and Broadway shows.

Gurwin's vent applicant referral base has expanded throughout the tri-state area, as professional and consumer awareness of the quality of our services broadens. We usually have a waiting list of three or more approved applicants for this program. The multidisciplinary team has gradually attained a high level of clinical and support service collaboration, a product of their expertise and mutual respect. We believe the quality of care and quality of life of our vent-dependent residents in this two-year- old program has been exceptional. We will continue to fine-tune the various clinical and support aspects of this program, and look forward to developing its outcomes measurement, research, and community education elements in the future.

Developing and implementing divergent programs requires ongoing organizational flexibility, problem-solving skills, and multidisciplinary collaboration. To date, our AOS and vent programs have undergone continuous system and strategy refinements. These programs, while "high touch" and "high tech" respectively, have each presented a myriad of administrative and clinical challenges.

Bryan Werner is the administrator of the Gurwin-Jewish Geriatric Center. For further information phone [phone], fax [phone] or visit www.gurwin.com. To comment on this article, please send e-mail to [e-mail]