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Getting started with subacute.


As I think back to when all this started, I remember when Diagnosis Related Groups were implemented in the early 1980s and the shock wave it created. Acute settings were scrambling trying to understand the new system and, most importantly, how to make money. It didn't take long for the private insurance industry to follow the same model, and the private market for subacute patients was born. Nursing homes began to see more complex clients and needed to make the necessary adjustments.

In 1986 I focused my attention on the medical needs of our residents and assessed how effective our physicians were at managing them. We had what I considered to be a standard structure for delivering medical care: There were five physicians who made up our core staff, all of whom were community doctors who had nursing home patients as a major portion of their practice. They relied heavily on our nursing staff to assess patient needs and, in many cases, sought out the nurses' advice on how to treat the patients. It became very clear that the medical staff desperately needed upgrading.

I began a search for a new medical director who I believed would be the key to changing the entire staff. I notified the area hospital division chairs of Family Practice and Internal Medicine that I was seeking applicants. In response, I received a few applicants who fit the traditional model. One of the interested parties turned out to be a representative from a hospital-based physician group interested in establishing a teaching program and using our facility as a site for medical students. After a great deal of thought and discussion with the Governing Board, we decided to try the teaching program.

This posed many challenges in structuring the agreement. The physician group is a subsidiary of a non-profit hospital and we are a for-profit corporation. Furthermore, our history with the hospital had not been viewed as all that positive. The most critical question, though, was the funding of both the administrative time for the designated medical director and the faculty for the teaching. We were finally able to convince our Board that paying for more clinical capability would be worth it from the standpoint of quality of care and the facility's image in the community. We anticipated that we would receive more physician referrals because of this.

Once the agreement was set, the first challenge was to attract new medical staff that would both meet our patient's needs and serve as faculty for the residents and fellows. The new medical director was instrumental in achieving this goal. It took some time; our medical staff membership was slowly converted from community physicians to hospital-based physicians. Their skills enabled us to significantly upgrade our quality of care.

Long discussions were held with the medical director to evaluate the types of patients who would best meet the needs of the nursing facility and provide the types of experiences that would give the residents and fellows a comprehensive exposure to the varying needs of the skilled care geriatric population. Subacute programs seemed to offer opportunities for the nursing facility to accomplish this and other goals, i.e., to establish new service lines to attract residents and position ourselves as an institution that could meet the needs of the hospital to discharge patients more quickly.

In 1986 we opened our first subacute program, a ventilator unit. The medical director recruited a pulmonologist as a consulting physician to assist in establishing program protocols and to be available for consulting on treatment decisions. This proved, however, to be a difficult program to manage. Besides the significant demand put on the nursing staff by the technical needs of the patient, we were faced with families and patients whose expectations were based on their experience in the hospital.

We addressed this by teaching our staff that "you're in a nursing home, not a hospital" was not an adequate response. We instructed them on the emotional needs of these patients and families and encouraged them to cooperate with the social service department in trying to meet these needs. Eventually our four-bed ventilator unit began to work well.

We then reached the next decision point: whether to expand the ventilator unit or look to new units for growth. We decided that expanding the variety of programs would be a better approach to maintain the integrity and interest of the teaching program, and we began to evaluate rehabilitation.

Specifically, we identified post-operative orthopedic rehabilitation as an area that was under-served in our community. Rehabilitation appeared to pose advantages for the facility in that it was not as high-tech an environment as ventilator support, and because of this, we were able to establish it as a significant presence in our facility. It eventually evolved to a 40-bed unit.

Once therapists were brought aboard, the medical director recruited a physiatrist as a consulting physician to work with them in a team conference format to review therapeutic goals and otherwise teach and support them. This has been invaluable in upgrading the skills of our team and expanding the service over the past five years.

Unlike other subacute programs, rehabilitation attracts the more independent client who has a single primary clinical need, as opposed to the complex client with multiple clinical needs and all the challenges that come with them. This was a significant advantage, since as competition with other facilities in our area, particularly assisted living and CCRCs, continued to grow, I was faced with the reality that the more independent resident was diminishing in our census. The rehabilitation program has proven to be an effective means to address this problem.

However, since this is a short-term, transitory population, we were faced with new operational challenges. These patients turn over every three or four weeks, and to maintain census, we find it takes approximately three to four short-term rehab clients to equal one long-term client. This, of course, means a lot more work for nursing and social work, and our marketing team has expanded to include not only the administrator, executive director and director of marketing, but admissions staff and our directors of therapy. However, at a reimbursement rate of $225 a day, as opposed to $110 a day, we have found it to be worth the extra effort.

Dialysis was the next program we developed. This population was identified by the local hospital staff as a difficult-to-place population. Meeting their specific clinical needs over and above nursing interventions proved to be a real challenge. Historically, our residents on dialysis would be transported to an off-site clinic to receive treatment, which would keep them out of the nursing facility approximately five to six hours three times a week. The negative effect this had on their quality of life goes without saying. We contracted with a home care company to have them come into our facility to provide dialysis. This proved to be a great success. Our program grew steadily -- until Medicare reduced its funding for home dialysis. The home dialysis company discontinued our service agreement, and we have been unable to find a satisfactory replacement since.

Hospice care was another clinical program we established. It qualifies as a subacute service because of its emphasis on pain management. It did, however, get off to a rocky start. Initially I was approached by a community hospice provider asking to have their agency come in and provide support services for our terminal patients. The agency representative informed me that separate funding was available to their agency and that, therefore, this would not pose any additional cost to our facility. However, in investigating this agency, I discovered that they were approaching all the facilities in our area and signing up as many as they could. This left me feeling that this agency had no interest in partnering with us, but was only seeking quick referrals for themselves. I did think, though, that the needs they pointed up were legitimate and that we had to figure out a way to meet them.

There was, in our area, a small local volunteer hospice agency that had been initiated through a joint effort by three local hospitals. I contacted the agency's executive director and began discussions regarding their providing hospice services for our facility. The initial response was that they were only providing services in clients' homes. I managed to convince the agency director that, since our facility had a teaching medical faculty, this would be a good place to develop the program. The agency agreed.

What are the general lessons I would draw from this? Basically, the formation of partnerships has been the cornerstone of our program's success. If both partners are vested in each other's success, positive results are more likely. If it is an arrangement solely of convenience for one or the other, it is destined not to last.

Among the many other benefits has been the positive effect on our facility's staff. The staff's frequent interaction with skilled physicians and other specialty-trained clinicians has been outstanding for morale and has enhanced our ability to retain them and attract new staff. Staffers themselves have reported as much.

In summary, I believe that the role of the medical staff in a nursing home is pivotal, not just as a manager of care for patients, but as team members in creating a dynamic environment that is adaptable to the varying needs of the patient and the surrounding community. Supporting these roles is the critical responsibility of administration. By executing this effectively, the facility expands its opportunities to meet the new challenges facing nursing homes in the 1990s.

Eli Pick, a licensed nursing home administrator for 15 years, is General Partner of the Pick Management Group, which has management responsibility for Ballard, a Chicago-area health care residence, where he serves as executive director. He is on the Board of Directors of the Illinois chapter of the American College of Health Care Administrators.
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Title Annotation:dealing with patients afflicted with nervous system-related ailments
Author:Pick, Eli
Publication:Nursing Homes
Date:Jul 1, 1993
Previous Article:Prospects for quick health care reform fading.
Next Article:Building new therapy centers and avoiding the pitfalls.

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