Technology helping make subacute care a reality.

New equipment and management systems are evolving that will enable nursing homes to do the job

Subacute care is offering nursing homes new opportunities and challenges. One of those challenges is efficient collecting and tracking of patient information for everything from billing to analysis of treatment outcomes. Another is the integration of new equipment.

An example of the technological innovation occurring in information management for subacute care in the nursing home is taking place at NovaCare, a provider of rehabilitation services to more than 2,000 health care facilities, most of them nursing homes, in 40 states. NovaCare is installing a new integrated information-management system for subacute rehab services that combines administrative and clinical applications in a single database and computerized management program. The system, NovaNet PLUS, collects data on events, procedures, and treatments as they occur. Scheduled to go into effect in three stages, or releases, the software works in the Windows environment, replacing an early DOS-based version.

Release 1, scheduled to be completely installed in approximately 1,700 NovaCare client facilities by the end of 1994, deals primarily with administrative aspects. Patient facts and payment information is entered into the system. Processes and results such as diagnosis, disability, acuity, length of rehabilitation and gain in function are tracked. Charges are calculated and payment sources identified on-line.

Releases 2 and 3 are scheduled to be implemented throughout 1995. Release 2 will enable clinicians to enter data on laptop computers and perhaps even handheld units at bedside. It will allow specific clinical assessments of patients in rehabilitation to be recorded and continuously followed, and it will assist in processing claim forms submitted to payers. Release 3 will add an improved system of collecting and analyzing the outcome data that so many subacute purchasers demand.

When completely up and running, NovaNet PLUS will eliminate the need to enter data more than once, and will provide a way to share data among case management functions, patient outcome assessment needs and accounting processes. The system will link all aspects of a patient's stay and treatment into a single chain of events and their results, a chain easily accessed and assessed by NovaCare and its nursing home clients.

Meanwhile, the trend toward moving subacute patients into dedicated facilities more quickly creates new challenges. For example, an increasing number of patients in nursing home-oriented subacute units are ventilator-dependent or need other intensive respiratory therapy. In fact, JCAHO is identifying ventilator-dependent programs as one of four categories of patient-care programs it will survey as part of its proposed subacute accreditation process. To survive in subacute, though, nursing homes must provide these services at less cost to payers and to their limited capital budgets.

The result is a "technological revolution" at the nursing home level, according to Robert Eckerle, Director of Sales, Marketing and Development for Primedica, the nation's largest provider of contract respiratory care services. For example, Sandra Carpenter, Director of Purchasing, reports "a significant increase in nursing home use of heat moisture exchangers, devices that moisturize air as it is inhaled. They are fast replacing a heated humidifier for many patients because they cost less [under $5 vs. hundreds of dollars], yet provide effective treatment."

Another piece of innovative equipment Primedica is examining, and which is reimbursable by Medicare Part B for use in chronic obstructive pulmonary disease, is a system for computerized retraining of patients for diaphragmatic breathing. The system's computer uses a remote infrared sensor to non-invasively sense, analyze and continuously transmit to the patient's brain the rate and pattern of diaphragmatic respiration. This "biofeedback" enables the patient to reduce thoracic breathing and increase deeper, more natural diaphragmatic breathing.

As part of a new trend of technology transfer from home care to nursing homes, Primedica is beginning to use the Sullivan Nasal VPAP (variable positive airway pressure) System which operates similarly to a ventilator. It is far less expensive, however, and many patients who have been on ventilators can be put on a VPAP instead. For example, a patient who is mobile during the day but who needs respiratory assistance at night may be an ideal candidate. In brief, the Sullivan Nasal VPAP senses pressure in the patient mask rather than in the flow generator. This direct measurement of actual breathing behavior ensures accurate bi-level pressure delivery, independent of flow pattern.

"A VPAP system sells for $2,500 to $3,000, while a full-blown pressure-support ventilator can mn $20,000 and a portable unit about $6,000," notes Carpenter.

Evolution of equipment, as well as development of new information management systems, points up the key factor behind nursing home involvement in subacute care: They must provide subacute services effectively and measurably, at substantially less cost than would be incurred in a hospital setting, but with affordable equipment. These technological developments, if adapted appropriately, can make the dream a reality.