Friday, April 13, 2007
Wellness for the subacute patient: even though they're more acutely ill than most nursing home residents, subacute patients can use wellness programs,
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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[ILLUSTRATION OMITTED]
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.
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."
Advertisement
[ILLUSTRATION OMITTED]
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.
# posted by Medical Information : 5:12 AM
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