The pressure is on.

Customized care - it's a concept that's starting to take hold in the nursing home arena. More and more facilities are confronting the reality that, when it comes to resident care, one size does not fit all. Appropriate medical care means care suited to the case.

Two factors are precipitating this: 1) the increasing variety of elderly being cared for by nursing homes, ranging from the traditional population of chronically ill, to the subacutely ill, to the reasonably functional if somewhat disabled populations in assisted living, and 2) the growth of the managed care concept that health care should be cost-effectively tailored to the patient's real needs.

Nursing homes are in a particularly strong position to take advantage of the move to individualized care because they are part of a "product-rich" industry. The sheer number of product categories and variation within categories available to facilities opens up opportunities to custom-select and purchase products according to resident-specific needs. A product category in which this has become increasingly apparent is pressure relief support surfaces.

The "firm mattress" of yesteryear has given way to an array of mattress replacements, overlays and specialized beds accommodating various levels of skin risk and injury. The wise administrator recognizes that no one of these products will meet the needs of all residents; depending on the resident, some will fall short, others may provide very expensive overtreatment.

It's important to realize," says Thomas Stewart, PhD, vice-president of sales, marketing and clinical affairs for Gaymar Industries, a Buffalo, NY manufacturer of such products, "that today's concept is to give the resident as much support as he or she needs without giving too much, because we all pay for that 'too much.'" To help nursing homes and other providers match the product with the patient effectively and without waste, Dr. Stewart has created a resident assessment tool he calls STOPSS, i.e., Selecting the Optimal Patient Support. Surface. Dr. Stewart recently authored a chapter on this approach for the forthcoming book Decubitus Ulcer: Clinical Practice, soon to be released by Springer Verlag.

For the purposes of this article, he identified the three key resident factors that nursing home staff should assess in selecting the appropriate surface: "level of activity, level of mobility and sensory perception. There are other factors contributing to the development of pressure sores, but these three seem to be the key in selecting a support surface."

Such an assessment makes sense for two reasons, he notes. First, today's available products do fall within a continuum of patient need. According to Dr. Stewart, the "minimum" is the foam-constructed mattress replacement; its specially engineered design provides an advantage over the traditional mattress. Moving up the severity-of-risk scale, there is the air mattress overlay (with pump attached); the low air loss overlay; the low air loss bed ("although the superiority of this over the overlay has not been scientifically documented as yet"); the flotation therapy bed; and, finally, the air-fluidized bed. There is also the turning bed, which periodically repositions the patient from side-to-side to avoid fluid build-up in the lungs for patients whose respiratory systems have been compromised by immobility; some of these products also provide a percussive element to help loosen lung secretions.

Also increasing the importance of selectivity in this category are the changing realities of Medicare reimbursement. Gaymar reimbursement specialist Colleen Kraatz explains, "As it stands now, pressure support surfaces are grouped into three reimbursement categories. Group 1, for patients at-risk, includes alternative pressure pads, foam replacements and air overlays; Group 2, for stage 2 pressure sores and higher, includes low air loss mattress replacements, low air loss overlays and beds, and alternating (or turning) mattresses; and Group 3, for the most severely disabled or contracted patients, includes air-fluidized beds. Groups 2 and 3 are considered ancillaries and are therefore fully reimbursable; Group 1 products are subject to routine cost limits.

"The problem," she notes, "is that if a prospective payment system (PPS) is enacted, as is anticipated this year, these distinctions may disappear. The facility may have to carry the cost of the surface it chooses within the single PPS payment." In other words, the product selection will have to be genuinely needed and cost-justified or the facility may lose money.

The possible good news is that the documentation criteria governing that reimbursement may be more uniform and easily understood than today's hodge-podge of intermediary-specific policies and interpretations. Perhaps a more uniform set of assessment standards, like Dr. Stewart's STOPSS system, will enable facilities to make truly rational selections among the products available to fit the products to their particular resident populations.

Which means that the pressure relief support surface market may provide an excellent test case for whether PPS really does fulfill the goal that has been set for it: to facilitate customized care supported by justifiable reimbursement.