Wellness for the subacute patient: even though they're more acutely ill than most nursing home residents, subacute patients can use wellness programs, too.

Wouldn't it be fabulous if nursing homes were paid for empty beds rather than being reimbursed for filled ones?" asks Cheryl Field, MSN, RN, CRRN, director of Clinical and Reimbursement Services at LTCQ, Inc., in Lexington, Massachusetts. "If that were the case, they'd do better at keeping people well in the community."

Obviously, the reimbursement system will never change that dramatically. But the possibility of not only getting people well, but keeping them that way, does exist in the subacute care community. The best place to start, says Field and others in the industry, is through the introduction of wellness programs.

Such programs are indeed beginning to spring up in subacute facilities throughout the United States, offering a holistic approach to getting short-term residents back on their feet and keeping them from coming back to the SNF. But unlike restorative programs, in which the goal is to maintain a long-term care resident's highest level of function, wellness programs are meant to wean subacute patients away from their reliance on facility staff and toward self-reliant living at home.

Kathleen Sullivan, RN, MN, CS, CRRN, is assistant director of nurses at Greenbriar Terrace Healthcare in Nashua, New Hampshire, a 300-bed facility with 55 beds licensed for skilled subacute care. As part of the Kindred Healthcare chain, Greenbriar uses the Care Map, a proprietary tool that effects a seamless transition from hospital to Greenbriar to home (figure). "As they come through our doors, we have two sets of goals in mind: short-term and long-term," says Sullivan. "For the short term, we have to make sure that we are able to pick them up from the hospital level of care--be it IV therapy, PT, or whatever was going on at the hospital--and then continue treatment. As far as long-term goals, we sit down with the patient, family members, case manager, and a representative from nursing to construct the Care Map. We plan out what we need to do to get patients back to their prior level of function. We also need to ask some basic questions, such as 'How many steps are there to get into the house?' Knowing what questions to ask is a big thing."

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There was never a question as to whether Mrs. Thomas was going to go right home after her discharge from the hospital. She'd been admitted with a diagnosis of cellulitis, which developed after she badly cut her lower left leg while closing a car door. She was responding well to IV antibiotics and would have been able to return home with the help of visiting nurse services, which would continue to oversee therapy. But Mrs. Thomas would not allow "strangers" into her home, plus she needed help with wound care. Neither of these conditions would have qualified her for Medicare benefits to cover her stay at Greenbriar, but the fact that she suffered from congestive heart failure did. Because she was spending so much time in bed, muscle weakness was setting in and fluid was gathering in her legs.

Once at Greenbriar, Mrs. Thomas received PT five days a week. They encouraged her to be up and about for specific periods throughout the day. When she was in her room, her legs were elevated to promote circulation and healing.

All was well until about day 14, when she became agitated, saying that she "needed to take care of some business." She fully intended to leave against medical advice. And that's where the Care Map kicked in. Adjustments were made, and Greenbriar's staff worked with Mrs. Thomas so that she felt free to address her business, leaving her confident that she remained in charge of her life. As a result, when she was discharged after nearly a six-week stay, she was able to resume her life where she had left off. She'd had sufficient time to practice climbing stairs at Greenbriar, was better able to understand her medication schedule, and was proficient at the minimal self-care her wound still needed after practicing with the nursing staff.

Had she gone home when she wanted to, Mrs. Thomas could have injured herself as she tried to cope alone, possibly ending up back at the hospital. The Care Map--the wellness component of her care plan--was her safety net.

"All in all, without the Care Map, somebody could really fail badly from either lack of preparation or from being discharged from subacute too quickly," says Sullivan. "In the dollars and cents of it all, if this is done correctly, the patient won't go back to the hospital, which is a much larger daily cost."

"We used to call it a phaseout, as in 'let's phase us out of their lives,'" notes Field. But now the push is for more than just mobility--it's for the promotion of restored independence. "Basically we're teaching patients how to seek out the services they need or acquire their medicine on their own so we can make sure they've learned these new behaviors and can maintain and use these new skills at home." Field also suggests that, for example, as a subacute patient nears the end of her stay, she have her own bedspread at the facility so that the week before discharge, she can practice making her own bed: "If she's going to trip on her bedspread, let her do it here so we can teach her how to avoid it. The bottom line is that right now, the way things are, we're creating dependent people. We should encourage them to do things for themselves a week before they leave instead of returning home and having problems."

Wellness is the aim of the Vitality Program, a centerpiece protocol for several communities under the Front Porch umbrella--Southern California's largest not-for-profit provider of senior living care communities (a total of 13 CCRCs, ALFs, and SNFs). Front Porch Corporate Vitality Program Coordinator Peggy Buchanan is based at CCRC Vista del Monte in Santa Barbara, where she is also the director of Fitness, Aquatics, and Physical Therapy. She says that the philosophy behind the Vitality Program marks a shift from the medical model of "what's wrong with someone" to one in which an exuberance for life is the goal. "It's not what we can't do, it's what we can do," says Buchanan. "Let's incorporate everything we can do."

And that's what the Vitality Program strives to do. It incorporates six dimensions of well-being: physical, social, vocational, emotional, intellectual, and spiritual (table).

"For example," Buchanan explains, "in an exercise class, there's more going on with individuals than just moving their arms and legs. Intellectually speaking, we like to teach them how their recovery process is best achieved. We gather the participants in a group setting, which enhances their social well-being. Gaining physical strength gives them self-confidence, which boosts their emotional well-being, and all of that together helps the spirit."

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Vista del Monte's Health Center Vitality Program Coordinator Roseanne Bezdek concurs: "If you have someone with a hip fracture, you're not just rehabbing the hip. It's much more than that. You're also training him or her on how to keep healthy, so you're also working with the individual on an intellectual level. And those are just two dimensions."

For an example of how the Vitality Program works you needn't go further than the monthly calendar. "This month's theme is outdoor fun." says Buchanan, "so we'll be taking a beach walk where we'll collect shells and talk about minus tides--what makes them so low, and what makes them so high." Each of the six dimensions will be covered by the beach walk: It's both physical and social. Communicating about the artifacts they find will help the participants form a spiritual connection with nature as they enjoy an emotional journey back to a youthful visit to the beach. Talking about the tides will provide intellectual stimulation, and using their specimens to make craft projects back at the facility will provide the vocational component.

Outdoor Fun Month will culminate in a campfire, where residents will physically participate in building the fire and roasting marshmallows. The social occasion will offer the sounds, tastes, and smells that evoke emotional memories of a spiritual visit with nature. And the residents who participate in the planning stages will benefit from the intellectual and vocational aspects of the program.

Information from the Vitality Program cites a 1995 study by Tufts University reporting that sedentary 80- and 90-year-olds are able to improve their muscle and bone strength by as much as 150% in 12 weeks. Granted, the average stay of a subacute patient is far shorter than 12 weeks--but who's to say that data such as these couldn't help a subacute patient build on the momentum established during an average 14- to 30-day stay? Says Bezdek: "Many times our patients will actually leave in better shape than they were before their fall or stroke."

Buchanan says that the Tufts study is used as proof for the more than 500 Vista del Monte residents and community members who access the Health Center that virtually anyone can fortify his/her physicality: "To be able to improve their muscle and bone strength in 12 short weeks--that's enough right there for older adults to relate to. Even those in the nursing home who are wheelchair-bound are showing improvements."

An increase in interest in the wellness concept has been the impetus for even more specialized programs. The Cardiopulmonary Conditioning Program was established by Terence Schiller, MD, at the Medford Care Center in Medford, New Jersey. Its sole purpose is "to cut down on the facility's rehospitalization rate," says Program Coordinator Vickey Elstone, LPN. "We'd like to help our subacute patients achieve a healthier, more comfortable, better quality of life. And it's a team effort by our physicians, RNs, PTs, OTs, SLPs, dietitian, and social services." While performing conventional therapy, the facility's therapists also teach cardiopulmonary patients efficient ways to perform everyday tasks while conserving energy and avoiding shortness of breath.

"During therapy, the therapists teach the patients breathing techniques. I continue the instruction later on at bedside. We monitor their vital signs closely, including pulse ox [pulse oximetry], in an effort to increase their endurance and overall physical conditioning," says Elstone.

The package is completed by the nurses who review with the patient and family members the meds, their side effects, and their proper administration, as well as any insulin and nutritional information specific to diabetics, colostomy care, and so on. "We pretty much do whatever we need to do for everyone, no matter what their condition. That's one of the special things here--the teaching part," notes Elstone.

An added aspect to the program at Medford Care Center is a brand-new 1,200-square-footgym. Director of Rehabilitation Shiv Shah, MPT, chose the equipment for the program, including a treadmill with a specialized geriatric arm; a recumbent bike with geriatric aerobic, cardiovascular, and manual programs and a large display for the exerciser; and a stepper that can be used either sitting or standing.

"We're hoping to continue to expand on our wellness concept, so hopefully the teaching aspect will grow, as well," says Elstone.

Wellness may be a good idea--but who's going to pay for it? The surprising answer is that if wellness is incorporated into the normal therapy and nursing routines, it is picked up as part of the overall inpatient stay by Medicare. "The services provided for the patients are already calculated into the different RUG categories," says Medford Care Center MDS Coordinator Sally Corpuz, RN. "So the services just add up. If the patient is solely on medical monitoring without rehab, it will go to the Clinical Category. If they're on rehab, it will go to the Rehab Category."

It really comes down to redirecting our thinking in terms of planning patients' days. Perhaps we can take that a step further--as Field suggests, maybe we should start referring to subacute facilities as "short-term wellness centers."

Table. Front Porch Corporate Vitality Program

Six Dimensions  Examples
of Wellness     of Programs

Emotional       Support groups
                Journaling
                Counseling
Intellectual    Workshops and classes
                Computer classes
                Memory stimulation
                (games, puzzles)
Spiritual       Bible studies
                Chapel
                Meditation
                Nature connection
Social          Group activities
                Birthday parties
                Happy hours
Vocational      Volunteer work
                Mentoring
                New hobbies
Physical        Aerobics
                Arthritis aquatics
                Line dancing
                Walking group
                Fall prevention
                Health screenings

Supplied by Vista del Monte

For more information on wellness programs, contact:

Reimbursement for Wellness Programming

Cheryl Field, MSN, RN, CRRN, Director of Clinical and Reimbursement Services, LTCQ, Inc., Lexington, Massachusetts, [phone]

The Care Map

Kathleen Sullivan, RN, MN, CS, CRRN, Assistant Director of Nurses, Greenbriar Terrace Healthcare, Nashua, New Hampshire, [phone]

The Vitality Program

Peggy Buchanan, Front Porch Corporate Vitality Program Coordinator and Director of Fitness, Aquatics, and Physical Therapy; and Roseanne Bezdek, Vista del Monte Health Center Vitality Program Coordinator, both at Vista del Monte CCRC, Santa Barbara, California, [phone]

The Cardiopulmonary Conditioning Program

Vickey Elstone, LPN, Cardiopulmonary Conditioning Program Coordinator; Shiv Shah, MPT, Director of Rehabilitation; and Sally Corpuz, RN, MDS Coordinator, at Medford Care Center, Medford, New Jersey, [phone]

Tobi Schwartz-Cassell is a healthcare/business writer based in Cherry Hill, New Jersey. She is coauthor of the book Adding Value to Long-Term Care: An Administrator's Guide to Improving Staff Performance, Patient Experience, and Financial Health (Jossey-Bass, Inc., available from www.elderclinical.com). For more information, call Schwartz-Cassell at [phone]. To comment on this article, send e-mail to [e-mail]. For reprints in quantities of 100 or more, call [phone].