Juggling the needs and goals of long-term residents with those of short-stay patients has become the new norm for many long term/post-acute care centers. The same skilled nursing care center regulations apply to both demographics.
However, providing quality person-centered care and a homelike setting for long-stay residents while providing rehab and preparing short-stayers to return home at their previous functioning levels requires keeping a lot of balls in the air.
To effectively care for short-stay patients, centers can build on their experiences with long-stay residents, but they need to implement new programs, policies, staffing models, and team training to enable these individuals to meet appropriate goals and safely return home.
“This is uncharted territory,” says Lyn Bentley, MSW, vice president of quality and regulatory affairs at the American Health Care Association (AHCA). “Short-stay patients are a different population, and we need to be prepared to address their unique needs, goals, and issues.”
The Long And Short Of Short-Stay
Short-stay patients most commonly come to post-acute and long term care centers for rehab after a hip or other joint replacement, stroke or heart attack, accident that results in a brain or spinal cord injury, amputation, or fracture. Their care usually involves physical and other therapies to address loss of or problems with mobility/balance/coordination/strength, speech and communication, swallowing, cognition (such as problem-solving and memory), and vision or perception.
Rehab professionals help patients maximize their function according to their individual abilities, needs, and goals. It may be as complex as helping a young man paralyzed in an accident be able to return to college and complete his degree, or as basic as getting a healthy senior back on the golf course after a hip replacement.
Treatment Teams
The treatment care team for a short-stay patient involves many of the same professionals who work with long-stay residents. These include the medical director, nurses, physical therapists, occupational therapists, speech/language therapists, social workers/case managers, psychologists, and dietitians. Short-stay patients may need to see some practitioners, such as their physician and various therapists, more frequently, and sometimes every day.
“There is an expectation that the short-stay patient will be with other short-stay patients. Intermingling of short- and long-stay patients is difficult. And you need to be prepared to provide a different level of care,” says Jill Bosa, chief operating officer of the post-acute segment at Signature HealthCARE. For the short-stay patient, “this care must be patient-centered, fast pace, interdisciplinary, and transitional in nature. Discharge planning really starts from day one,” she says.
Bosa suggests that specific nurses and certified nurse assistants (CNAs) work exclusively with short-stay patients. These should be nurses and CNAs who like the pace of the short-stay unit, are comfortable working closely with the rehab and therapy team, and understand the importance of letting patients do more for themselves (such as bathing and getting out of bed) as they seek to regain functioning. “Someone who has been in long term care for their entire career might have a harder time adjusting to working with short-stay patients,” she says.
Bosa suggests that the nursing staff who choose to work with these patients receive some special training about rehab’s role and the unique goals, objectives, and needs of this patient population.
Rehab Setup
“We have special units for short-stay patients,” says Julie Britton, vice president of clinical operations for Genesis HealthCare. “The care process is specific to the patients’ needs in each unit. We communicate with the hospital and ensure that our staff are trained to handle special criteria such as ventricular devices and other heart monitoring.” Elsewhere, she says, “At some centers we have pools for water therapy, and we may have two shifts of physical therapy and a pharmacy that can expedite orders and discharge medications.”
Genesis offers special services and has specialists it can call to provide them, she says. “In some cases we may have to get everything done in seven to 10 days. It’s almost like a mini hospital.”
Before a short-stay patient is admitted to a skilled nursing center, the team should conduct a pre-admission screening to review the patient’s condition, prognosis, and history. This is designed to determine patients’ needs so that they can be matched with appropriate services available at the center. If the center determines that it is unable to meet the person’s needs, the patient should be referred to one that is better equipped to meet them.
It is important for the nursing center to have strong relationships with acute care hospitals, which have a vested interest in ensuring that patients are able to return home and do not experience complications or problems that result in readmissions.
“Better understanding of the patient’s clinical status before admission and a better ‘handoff’ from the hospital are key to improved care coordination and lend to the speed needed for success with a short-stay patient,” says Bosa. In turn, the skilled nursing center “handoff” to home health/outpatient services is just as important for the transition home.
This coordination is starting sooner as well—while the patient is still in the center, Bosa says.
Great Expectations
Managing short-stay patients’ expectations is critical. This starts before the patient is discharged from the hospital. First and foremost, the patient expects quality care, and there are many keys to providing it in a long term care setting. “Most short-stay patients have expectations related to amenities offered at the center, for instance, a private room, television, and Wi-Fi,” Bosa says.
Goal setting must have a patient-centered component, she adds. “The patient’s goal is to achieve his or her maximum level of function. It may be to return home with a cane or other assistive device. It is essential for the interdisciplinary team, led by the physician, to develop realistic and appropriate goals for the patient.
At a minimum, says Alan Horowitz, a partner in the legal firm Arnall Golden Gregory in Atlanta, “Therapeutic goals should ideally be for the patient to return to his or her prior level of functioning, if realistic and attainable.” He notes that pursuant to the recent Jimmo v. Sebelius settlement, improvement is not required to obtain Medicare coverage.
Setting Goals
The care team needs to understand the patient’s goals and agree on the time frames in which to meet them.
“Based on realistic goals and expectations, the team works with the patient and family to develop a plan of care to help him or her achieve these goals and return home,” says Daniel Ciolek, PT, MS, PMP, associate vice president of therapy advocacy at AHCA. Bosa adds, “Care planning really must occur in the first 24 hours, especially when the patient might only be there for three to five days. This requires a different mindset.”
Several questions must be addressed in developing this care plan for short-stay patients, Ciolek says, including:
■ What was the person’s functioning level prior to the illness, injury, or other event that sent him or her to the hospital? This is an essential and basic question. Walking two miles a day might be a realistic goal for a healthy 55-year-old following a hip replacement but not for a 75-year-old with COPD and arthritis who was unable to walk without assistance prior to surgery. Knowing where the patient was before can help determine where they might realistically go.
■ What supports does the patient have? It is important to understand if patients have family who can help them when they return home and what kind of assistance they can provide. This requires talking to both the patient and his or her family to ensure everyone is on the same page. “We had one patient who said her husband would be able to help take care of her and help her with all of her needs. When we talked to him, he said he had to work and be away most of the day,” says Bosa.
■ How motivated is the patient? A person who needs to go back to work and/or has children to care for after recovery is likely more motivated than a retired single person with a sedentary lifestyle. The motivated patient is more likely to welcome ambitious therapy that gets him or her home and back to work more quickly.
■ What kind of home will the patient be returning to after leaving? It is important to assess the home environment and address issues such as the need for handrails and grips and eliminating fall risks such as loose rugs or a high bed. It may be useful for a social worker to meet with the patient to discuss the need for supports such as Meals on Wheels, rides to and from physician appointments, medication reminders, and help with cleaning.
■ What are the patient’s and family’s expectations during the stay? It is important to know if the family expects to take the patient out for meals, family events, or other activities. This could have implications for both the center and the patient if something were to happen—such as a fall—when the patient leaves the center, even if it’s only for an hour.
A Daily Care Plan
Care plans for short-stay patients must be reviewed much more frequently than those for long-stay residents. The shorter the person’s designated stay, the more frequently the care plan should be reviewed.
“Communication is key as the patient is going through therapy and rehabbing,” says Bosa. “Most of the time, we can tell quickly if they are motivated and if they have a supportive family.” At the same time, the team needs to be able to quickly recognize if the family isn’t or can’t be supportive or if they disagree about care goals.
“If the family has different viewpoints, let’s get together and discuss them honestly,” she says.
The care team members need to be keenly observant and able to respond to situations and changes quickly. The center doesn’t have the luxury of time with short-stay patients. Be prepared to make the most of time spent on care planning and opportunities to discuss goals and progress, Bosa stresses. “The pace is amazing. Patients are moving through the continuum quickly.”
Should I Stay Or Should I Go
The center must protect patients’ rights. If someone wants to leave the center for a family event or dinner with friends—even for just a few hours, the person has that right. However, the center still has responsibility for that person’s well-being.
Patient and family education is key to keeping short-stayers safe. As Bosa says, “When the patient truly understands the benefits and risks of medications, for example, he or she is more likely to be compliant. Patients also are more likely to self-identify and seek help if there are wide effects or issues that arise.”
When possible, it may be helpful to have the patient and family practice such actions as walking down an aisle or administering an injection. This enables the team to identify, troubleshoot, and prevent potential problems. Ciolek says, “It is important to sit down with the family, discuss the care plan, and address the possible risks of taking the patient out of the center, for example, how it could cause problems if they don’t get their medications at a specific time.”
The good news, says Bosa, is that “short-stay patients generally want the focus to be on goal achievement. The typical short-term patient is less interested in spending time away from the center. This is because rehabilitation is too important as he or she is very engaged in achieving goals and improving function.”
Nonetheless, it can be helpful for centers to have
policies and procedures in place that address what information, documentation, and planning will be necessary when a short-stay patient goes off-site.
Unfortunately, patients may become impatient with their progress and insist on leaving before the center team thinks it is safe or appropriate. Whenever possible, of course, the best way to address this situation is to prevent it from happening. “Collaborative goal setting early in the stay should alleviate future issues with a patient wanting to leave against medical advice… . If we all agree up front on the functional goals for the patient to return home, there likely should not be an issue,” Bosa says.
Negotiating Departure
However, there may be times when the patient has one set of goals and the team has another. In these cases, “the team may ‘negotiate’ with the patient on goals if they are unsafe,” Bosa says. “Often, once the patient understands the team’s concerns and why there are concerns, there is no longer an issue.” Team members must communicate to patients that their top priority is getting them home as soon as practicably possible while avoiding rehospitalization and that the team is skilled in accomplishing this.
It also is useful to emphasize the big picture—the reality that a complication or setback could take them away from home for even longer periods of time, cost more money, and make it more difficult to reach their health care goals.
If the patient insists on going home or the family demands it and the physician is not in agreement, says Teresa Salamon, deputy general counsel at Genesis HealthCare, “we call this a discharge against medical advice.” Genesis will ask the patient and/or family to sign papers stating that they understand that the care team advises against the patient’s departure and that they don’t think it is safe for the person to go home. “In these cases, we will do what it takes to make it as safe as possible for the patient,” she says. “This includes scheduling follow-up appointments with physicians and calls or visits from a home health nurse.”
“We provide follow-up calls to the patient after discharge,” says Bosa. “We can help solve issues that may arise once the patient has returned home, answer questions that he or she may have, and provide resources that will improve the probability of success.”
If the situation is dire and the team feels strongly that the patient will be unsafe or in possible danger of some kind,
the center should contact the state ombudsman or Adult Protective Services.
Conversion To Long-Stay
In some cases, rehab won’t be effective, and it will be necessary for the short-stay patient to become a long-stay resident. Again, communication can make this transition smoother.
“If goals can’t be met and the patient needs long term skilled care, you need to discuss this with the patient and his or her family,” says Salamon. At this point, it is important to involve a social worker or case manager to discuss financial considerations and help the patient apply for Medicaid if appropriate. This can help soften the blow, as “the financial piece can be stressful or even devastating for families,” says Salamon. “The private-pay spend-down period can reduce a person’s resources quickly.”
However, Horowitz says, before giving up on therapy goals, consider why the patient isn’t making progress. “Get the entire team together—it is important to have as much input as possible. Maybe you’ll find that someone isn’t progressing because he or she is depressed, and no one has observed this but the CNA or social worker. Determining if unexplored issues exist may yield valuable results.”
It is to be hoped, Salamon says, that the transition from short-stay to long-stay doesn’t happen suddenly. “This shouldn’t be a surprise. You should be in constant communication with the family, and they should be receiving regular status reports,” she says.
If the patient or family seems to be seeing the situation through rose-colored glasses, the team needs to gently help them face the reality of the situation. It is okay for them to hope that mom can go home soon, but if this isn’t feasible, they should be warned not to expect it, Horowitz says, and all these conversations need to be documented.
At the end of the day, centers must comply with the applicable federal regulations. According to Horowitz, the regulations require that a skilled nursing center may not transfer or discharge a resident unless one of six conditions has been met:
■ Transfer/discharge is necessary to meet a patient’s needs that cannot be met by the center;
■ The person’s health has improved to the point where the services the center provides are no longer necessary;
■ A continued stay endangers the safety of the individual;
■ The health of other center individuals would be at risk;
■ After reasonable notice, the patient or a responsible party has failed to pay or arranged for Medicare or Medicaid to pay for staying in the center; or
■ The center no longer operates.
Planning is essential to protect both the patient and the center. “If there is no planning, trouble can happen,” says Horowitz.
For example, he suggests, “You can’t just assume that the family or home care worker will do the right thing. You need to reach out, ask questions, and make sure they have adequate training. This should be part of the discharge planning process. You are obligated to consider the environment the patient is being discharged to.”
Working with short-stay patients is challenging, rewarding, and exciting. However, it is also difficult.
“Long-stay is easier. There are no grand expectations that mom is going home or will be able to take a trip to Europe,” Bosa says. “We’re getting patients sicker, and we’re being pressured to get them out quicker. We’re not only expected to get them home quickly but enable them to stay there safely and continue their recovery.”
Short-term stays aren’t for every center, but there are tremendous opportunities for those that are nimble, graceful performers that can juggle without dropping a single ball.
Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.