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Green Briar: how one nursing facility moved toward increased sub-acute care.

In 1981, the Green Briar Rehabilitation and Comprehensive Care Center was not a particularly unusual facility. It had in-house departments of Physical Therapy and Occupational Therapy, with outside providers of Pharmaceutical Services, X-ray, Laboratory Services, and Speech Therapy. Respiratory Therapy services were provided in-house by a respiratory therapist who functioned more as a transporter than as a therapist. The center averaged 400 admissions each year, with an average census of 170 patients.

While Green Briar prided itself on its rehabilitation services, the number of patients covered by Medicare on any day averaged 18. The majority of patients were paying privately; we had no Medicaid or indigent patients.

The programs and services of 1992 bear little resemblance to those of 1981. The path taken required imagination, foresight and risk-taking of the highest order. Today Green Briar has in-house departments of Physical Therapy, Occupational Therapy, Respiratory Therapy, Cardiac Telemetry (an eight-bed unit), and Pharmacy. Outside services have dwindled to those of X-ray and some laboratory services. While the average census has decreased to 140 patients, the number of admissions has climbed to over 1,400 per year.

In fact, the past ten years have been revolutionary more than evolutionary. In 1989, according to the Health Care Cost Comment Board of the State of Florida, reporting on the financial status of nursing centers in the state, Green Briar accounted for over 4.00% of the ancillary health care revenues in the state - - a state where 484 nursing centers were operating in 1989. For Green Briar, this represented a growth of 700% since 1983, the year before DRGs began.

The Crucial Decision

The story of the revolution began in 1982. At that time, eight applications appeared before the Health Systems Agency of South Florida requesting certificates of need for nursing homes. Recognizing that expansion would come and that key staff is valuable, we gave our registered nurses and licensed practical nurses double the average wage increase granted to other employees. The increase in salary levels of professional nurses elevated Green Briar's wages to those of surrounding hospitals. And for the first time, the ratio of registered nurses to licensed practical nurses shifted to almost 50/50. The upshot was that the decision to meet hospital wages enabled Green Briar not to lose any nurses for economic reasons, even though ten new nursing homes entered the Miami market during the succeeding nine years.

The increase in salaries had one other benefit which became crucial one year later. In October 1983, DRGs went into effect. Much had been written about the effect DRGs would have on the discharge pattern of hospitals. Green Briar anticipated that sicker patients with higher acuity levels would be discharged sooner from local hospitals. Therefore, with the higher wages already in place, Green Briar increased its staffing of registered nurses, licensed practical nurses and nurses aides during August and September of 1983. The increased staffing was in place by October 1, 1983, in time for the anticipated influx of higher acuity-level patients.

However, the patients requiring higher acuity levels of care did not materialize during 1983. In fact, it was not until late 1984 that these patients began to flow from the hospitals. With the higher staffing levels already in place, though, Green Briar was uniquely positioned to accept the few more acutely ill patients who were discharged.

We discovered, as did the hospitals, that the rate of readmission to the hospital of these more acutely ill patients who were at Green Briar was no different than at pre-DRG levels. Furthermore, we found that patients with rehabilitative illnesses rehabilitated 20% faster than at pre-DRG levels. In fact, for a fractured hip, not only did the patient's hospital stay decrease by 20%, but the patient's nursing home stay also decreased by 20%. In sum, the first and most immediate result of the 1982 salary increases was Green Briar's ability to easily increase its staff to appropriate levels to provide proper care and rehabilitation to post-DRG hospital discharged patients, with decreased lengths-of-stay.

Growth Begins

Once Green Briar proved to hospitals and to the medical community that it could handle the higher acuity level patient (and that most other nursing homes were not yet prepared to handle these patients), hospitals began demanding increasing levels of service of Green Briar. In late 1984, the first ventilator-dependent patient came to Green Briar. The nurses accepted the patient as a challenge and rose to the task.

By the late summer of 1985, though, we realized that our nursing staff was strained beyond the breaking point, even though caring for ventilator- dependent patients who, at that time, numbered only 2. We responded by hiring respiratory therapists to work at first seven days each week, from 7 am. to 3 p.m. Then we expanded their hours to 12 each day. Finally, we decided to provide for 24-hour in-house coverage as this service grew.

Outside Support

In 1988, Green Briar knew that it could not make continuing financial commitments for program expansion on its own. Integrated Health Services, Inc., a major health care provider of medical specialty care units in the United States, came to the rescue. Integrated's Chairman of the Board, Dr. Robert N. Elkins, was a visionary in his sense of the shape of the future for Green Briar. Dr. Elkins believed that Integrated's support, both financial and programmatic, would enable Green Briar to expand beyond its initial attempts to create medical specialty units. After leasing Green Briar in 1988, Integrated added its strengths and visions to that of Green Briar, completing the transformation of Green Briar into a medical specialty-oriented health care facility.

Additional enhancements to the ventilator program were made in 1988 and 1989, when a new liquid oxygen storage system was constructed and a medical gas delivery system was added. The new storage system increased our maximum capacity from 15 patients to well over 50. Following the construction of the new storage system, a new medical gas delivery system was added to each room. The system contained a fine for compressed air, suctioning and oxygen. The addition of the system enabled the ventilators to operate off of compressed air, thus reducing the amount of heat generated within each room.

The Respiratory Therapy Program for tracheostomy- and ventilator-dependent patients has since then steadily grown. From an average of 1 patient per day in 1985, we averaged 3 in 1986, 7 in 1987, 11 in 1988, 14 in 1989 and 16 in 1990. This year we are averaging approximately 24 patients per day.

Expanded Services

The growth of the Respiratory Program inexorably led to an increase in the number of other patients in need of sub-acute services. By 1987, the percentage of patients requiring sub-acute services among those of our patients covered by Medicare was in excess of 33%, while the average for other nursing homes was closer to 8%. During the period of July 1, 1989 through June 30, 1990, the percentage of sub-acute patient days in the Medicare-certified part of Green Briar exceeded 75%.

To service this growing sub-acute population, two services were initiated. First, in 1989 our eight-bed cardiac telemetry unit was installed, with the South Miami Hospital providing the cardiac telemetry technicians and the equipment. The idea was to enable a cardiac patient to complete his cardiac recovery in the nursing center with appropriate monitoring, thus saving the hospital from patient days for which they received no additional income.

Although the system has been used for that purpose, a greater purpose soon became evident. Our data indicated that ventilator-dependent patients who were full codes tended to have cardiac problems during the first few weeks in the nursing center. By monitoring these patients during the first two weeks, we discovered patients experiencing problems early enough for appropriate intervention, either at the nursing center or with readmission to the hospital. Further monitoring during the stressful time of weaning a patient from the ventilator, as well as a combination of weaning and physical therapy, enabled us to discover many problems and to intervene in time.

Our telemetry unit averaged less than 1 patient during 1989. In 1990, the average had risen upward to slightly more than 2 patients per day. During 1991, as many as 7 patients have been monitored at any one time, with the average approaching 4 patients per day. This year the average has risen to 7 patients per day.

To support the sub-acute patients' pharmaceutical needs, Green Briar brought its pharmaceutical services in-house. Once again, South Miami Hospital assisted Green Briar in space planning, identifying the needed inventory and providing the personnel. Beginning this year, Green Briar assumed total responsibility for the pharmacy. With our own IV mixing station and our own unit dose system, Green Briar was able to provide unit dose medication to its patients in the same fashion as a hospital unit dose system.

The only medications Green Briar does not prepare are chemotherapy drugs, which are supplied through outside resources.

Florida regulation permits patients to supply their own medication as long as it is compatible with the nursing center's delivery system. Recognizing that no patient would be able to provide unit dose packaged medication, Green Briar made a commitment to its private paying patients to match the price, expressed in a unit dose basis, of any medication a family would be able to purchase through a recognized community pharmacy in the Miami area. Although this has reduced the profitability of our pharmacy, the expansion of medications, particularly IV's, provided to the sub-acute patients through Medicare and other insurances has more than made up the difference.

The benefits of an in-house pharmacy extend beyond those of greater profits. Medication is prescribed more accurately and is delivered more promptly. Emergency needs are quickly met, whereas with an outside service one has to encounter delivery delays. Finally, there is less waste; this in itself accounts for much of the increase in pharmacy profits.

In another move toward expansion, approximately one year ago, Green Briar ventured into the world of hospice care. Working with VISTA, Green Briar opened up a 10-bed hospice unit which since has been expanded to a 28-bed unit. With Green Briar's ability to deliver and serve hospice patients' complex medication needs, it was a "win" for both parties.

To explain, Green Briar's ability to meet patients' ancillary service needs was the key to providing a positive setting for hospice. VISTA provided the nursing staff, but looked to Green Briar to provide the ancillary services. For VISTA, we provided a "hospital setting" in a less expensive environment, free of the usual hospital overhead.

Finally, last year Green briar became the first nursing center in South Florida to provide services to ventilator-dependent pediatric clients. A ten-bed unit was designed and opened with the ability to expand the unit to 18 or 24 clients if warranted. Coupled with the adult unit, the total number of ventilator-dependent and tracheostomy patients should to between 30 and 40.

Next on our drawing board: a specialized wound-care management program.


Two observations are of interest. First, despite our facility's major step ahead in sophistication, we have not been required to obtain a certificate of need. This is largely because such activities as ventilator support and cardiac telemetry are, in essence, extensions of respiratory therapy and cardiac monitoring functions that we performed before. Second, the change in payment mix has been interesting to observe: though Medicare reimbursement has largely remained constant, private pay has given way in prevalence to private insurance reimbursement, as the illnesses of our resident trended toward the sub-acute.

One thing that has not changed is our philosophy of care expressed in 1983, immediately prior to DRGs being implemented: Green Briar should provide appropriate nursing care and services to any patient who was no longer in need of acute hospital services. It remains Green Briar's philosophy today.

Russell Silverman is Administrator of the Green Briar Rehabilitation and Comprehensive Care Center, Miami, FL.
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Title Annotation:Green Briar Rehabilitation and Comprehensive Care Center
Author:Silverman, Russell
Publication:Nursing Homes
Date:Aug 1, 1992
Previous Article:Bathing systems.
Next Article:Joining battle with the state over Medicaid.

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