ADVANTAGE – Long Term and Post Acute Care

Building a Better SNF

Health systems are re-examining their post-acute care strategies and SNF partnerships.

By Julie Schulz, MD

After steadily migrating out of the skilled nursing facility (SNF) market over the past decade,health systems are re-examining their post-acute care (PAC) strategies and the potential value of SNF partnerships. This renewed consideration is directly tied to health systems’ growing accountability for the quality and cost of services delivered across the care continuum, including the need to improve care continuity, reduce readmissions and improve patient and family satisfaction.
Aside from discharges to home, SNFs are the most common post-acute destination, representing 19 percent of PAC transfers. Partnerships with freestanding SNFs provide an effective option for hospitals to improve PAC quality and efficiency without the financial risk of ownership.
Readmission penalties and a shift toward bundled payment for full episodes of care will require hospitals to more actively oversee the services their patients receive after transfer to a SNF. Congestive heart failure and pneumonia, two of the three conditions for which readmission penalties began in 2012, are among the top 10 diagnostic-related groups for SNF admissions.Additionally, joint replacements likely will be among the first procedures to be reimbursed through bundled payments that include PAC, given their high volumes and expenditures among Medicare patients.
New Care Pathways
Cost per case, length of stay and readmission rates vary significantly across SNFs. Even compared with other PAC sites, SNFs have notoriously high risk-adjusted readmission rates. The most effective health system-SNF relationships will have both the right partnership structure and care delivery model to avoid readmission penalties and improve PAC. To begin, there areseven major building blocks that can optimize the role SNFs play within a system of care(clinical alignment and resource effectiveness). How an individual system prioritizes these building blocks will depend on its service portfolio and local market dynamics.
Care pathways: Ensure that hospitals and SNFs work together to develop evidence-based protocols that standardize and optimize care across acute and PAC settings.Care coordination: Form cross-continuum teams that cover both PAC and acute care sites to identify and address problems in care transitions, using coordinators to bridge both settings.Quality rehabilitation: Ensure that inpatient discharge planners are familiar with the therapy staff and technology available at area SNFs to select destinations that best meet patients’ rehabilitation needs. Alignment strategy: Inventory area PAC facilities to determine SNF supply and alternate PAC options. Identify top performers in quality metrics to help patients make educated SNF choices.This may include the decision to create a formal SNF network. Handoffs/communication: Engage hospital physicians to increase their accountability for handoffs and any subsequent read missions. Better link patients’ primary care physicians with emergency department physicians to avert avoidable admissions. Create comprehensive medication and personalized care records for all patients.Information technology: Explore software applications that enable discharge planners to search electronically for area SNFs that best match patients’ care needs. Automate data sharing with SNF medical directors on key quality metrics.Transfers/access: Utilize a standardized transfer form, formalize a referral system with area SNFs and facilitate real-time information on bed availability. Future Considerations: A number of variables must be considered when determining how SNFs factor into your system’s ability to optimize care across the continuum and respond to changing market conditions and payment models.  Begin by determining your organization’s short- and long-term strategy for working with — and possibly within — the PAC sector (i.e., partnership, ownership, conversion to becoming a PAC provider). Along with this, evaluate whether your organization intends to pursue bundled payment projects or risk-sharing models that will include PAC services.  Next,assess your current case mix of patients discharged to SNFs to determine the demand for rehabilitation services vs. medically complex services. Hold regular forums for collaboration between hospital and SNF medical directors, as well as chief nursing officers and PAC nursing staff. Forums should include the sharing of data on potentially avoidable admissions and readmissions and root cause analyses for problematic trends.

Giving Positive Feedback to Staff Nurses managers can empower staff to advocate for quality care.

By Joan M. Lorenz, RN, PMHCNS-BC

When Mildred Jones, RN, became the nurse manager on an acute psychiatric unit that had experienced a lack of leadership for many years, her goal was to raise the quality of patient care by advancing the staffs’ knowledge and empowering them to advocate for themselves and their patients. Each time Mildred walked through the unit her critical-thinking mind went into overdrive thinking about how much work needed to be done.  Occasionally, she pulled staff aside to alert them to the problems she noticed and shared with them the best practices for the current patient care situation. Her intent was to use point-in-time learning to raise awareness and provide guidance; however, some staff saw her actions as condemnation and ridicule. What could Mildred do? She asked for help from a trusted colleague and set about developing ways to give positive feedback.
Many nurses are like Mildred. Nursing education emphasizes critical thinking. Nurses are taught to approach patient care situations with an eye for what is out of place or needs attention. This makes us excellent observers and keen problem solvers. It becomes natural for us to enter a patient care situation and begin immediate analysis, often taking action and giving direction at the same time. Being able to do this is a great asset. But like any asset it can also be a liability as Nurse Manager Jones found out. Her critical thinking mind, allowed to dominate, looked for and found problems and immediately began to problem solve. However, this had negative consequences on her relationships with others.
Use Your Critical Eye to Find What Works
Giving positive feedback to others is crucial to any nurse’s work success and collegialrelationships with co-workers.  But many of us find that it does not comes naturally. Indeed, ifwe allow our critical thinking minds to take over, constantly seeking out problems, we often donot even see what is working well. Giving positive feedback to others takes practice. Whennurses become aware of an overactive critical thinking mind they can begin to practiceredirecting themselves to look for what is going well in addition for looking for what needsattention. So the road to giving positive feedback is to develop a more balanced approach to ourwork and relationships with co-workers. Allow your critical thinking mind to see what areas needto be addressed at the same time that you ask it to seek out what is going well and needs to beacknowledged and praised.  There are a variety of ways that you can balance your point of viewat work and help your critical thinking mind to become a more appreciative mind. Four things topractice include:
1. Developing an attitude of gratitude.
2. Actively looking for what is going well.
3. Letting people know how much you appreciate them
4. Using a gentle positive approach when giving constructive criticism
Develop an Attitude of Gratitude
How do you develop an attitude of gratitude? It’s simple – start by saying ‘thank you’.
In a work situation you can start by noticing the little things that people do each day. A simple’thank you’ can mean a lot. Go ahead – try it. Thank the CNA for making up the bed, combing the patient’s hair, changing the bed linens, or passing out the water for the patients. Thank a colleague for giving out medications on time, talking with a distraught family member, or taking the time to answer a patient’s question (even though it wasn’t his patient). At the end of the day,express thanks to your team members for making it a pleasant day. It is especially helpful to thank others when things haven’t gone so well, “Thanks for holding your cool today when everything seemed to break loose at the same time.”  When you do this you might see a smile creep across your colleague’s face – that in itself is a simple reward for your efforts. Of course,some might be suspicious of this new behavior. Reassure them by letting them know that you are trying to acknowledge what you have always noticed by kept to yourself. When you begin to say’thank you’ you might find too that you begin to notice more and more things to be thankful for.And who knows – it might become contagious.
Actively Look for What is Going Well
When you walk into a patient’s room remind your critical mind to look for what is going well notjust for what is not. Do not passively wait for something to strike you as going well. Seek it out.Some teams use a three-part evaluation for debriefing urgent work situations which can easily beapplied to any work situation. The evaluation asks the group to answer these questions:
What went well? What didn’t go well? What can we do differently next time?
This three-part evaluation helps give balance to the situation. By starting out with what went well we shift the emphasis to the positive and that gives us the opportunity to tell others know that we noticed their contributions. Using this evaluation also models for others a way to give positive feedback. After a stressful staff meeting, the team leader asked the group to list what went well. Members were able to list that even though there were a lot of differing opinions they liked that everyone was given time to express themselves and others were polite enough to listen.
Let People Know How Much You Appreciate Them
How do you show your appreciation of others? Are you genuine in your approach to those you work with? How often do you express appreciation to your team leaders, your Nurse Manger,you nursing administrators for a job well done? A simple “thanks for representing our views” at a hospital wide meeting can go a long way in letting your supervisor know that you appreciate her effort.
Use a Gentle Approach to Constructive Criticism
We all know there are times when we need to offer constructive criticism to others. Following these guidelines suggested by Susan M. Heathfield in “How to Hold a Difficult Conversation”might help make it go smoother. Seek permission to provide the feedback, saying for example: “May I offer a suggestion that might make that go easier for you?” Don’t just dive right in. Let the person know that you need to provide feedback that is difficult but important to share. Share what you’ve noticed in a kind way. Keep it centered on being helpful and on you and the other person. It’s counterproductive to say something like, “Everyone is talking about it.”  Keep it simple, e.g.: “I am talking with you about this concern because it impacts patient safety (goes against policy, seems to cause anxiety for the patient, causes confusion on the unit, etc.).”  Let the nurse know the positive impact her behavioral change will have on the situation. For instance, to a charge nurse staff complains is too aggressive, a nurse manager might say: “You understand the importance of staff working together in an efficient manner. But by lowering your voice and asking others for their opinions you can gain cooperation, reduce anxiety, and help us all get the job done faster”.  After applying some of these techniques to provide positive feedback Jones walks though the nursing unit with a better-tuned appreciative mind. Because she acknowledges the good she sees the staff are more receptive to her guidance because they now hear praise along with the instruction.

Vascular PRN now offers custom sewn pneumatic garments for bariatric patients
By Greg Grambor

Fitting a bariatric patient, particularly a very large patient, with lymphedema sleeves can be quite a challenge. Therapists,  LTC and hospital personnel go through a great deal of trouble, sometimes without a good outcome. Leg and arm sleeves are zipped together, two or three extension inserts are tried, often with little or no success in some of the largest patients. This is no longer a problem! Medical professionals can now contact Vascular PRN for custom sewn lymphedema sleeves. The company provides a measuring guide, measuring advice from trained experts, and in a few weeks, the patient’s lymphedema is being properly treated with pneumatic compression. Custom sleeves for amputees are also available, so now, no patient with lymphedema, no matter what the complication, needs to go without adequate treatment.
Prescribers are reminded that compression therapy should not be used during the inflammatory phlebitis process or during episodes of pulmonary embolism, congestive heart failure, pulmonary edema, suspected deep vein thrombosis or in any instances where increased venous and lymphatic return is undesirable. Vascular PRN may be reached at 800-886-4331.

Elderly woman stuck in nursing home elevator for 29 hours
by Robert Walker

As the holidays of 2012 wrapped up, millions of families across North America gathered to enjoy each others’ company, exchange presents and enjoy sumptuous food. But for one woman living in a Canadian nursing home didn’t have the chance to spend the holidays with friends; instead, she spent 29 hours stuck in the home’s elevator. As reported in the Sun News Network, 87 year-old Rosalie Rowsell, a resident of Malton Village Long Term Care Facility, a Toronto assisted living community, returned to the community in the evening of December 23 after spending time with family. It was then Rowsell is believed to have been stuck in an off-duty residential elevator, and although she did not return to her room that evening, staff believed she was still with her family. Rowsell was found 29 hours, still in the elevator, after her family realized she never made it home. The news source reports that she could not reach the elevator’s emergency button to call for assistance. She was eventually found on December 25 in the elevator, and after being taken to hospital, she was released the same day. As a result of the incident, the Ontario Ministry of Health and Long-Term Care is conducting an investigation to determine what went wrong. The assisted living community is apologetic, and vows to prevent any such incidents in the future. “We sincerely regret that this gap in our duty resulted in endangering a resident and causing her family distress,” Emil Kolb of the Region of Peel, which operates the facility, told the news source.

Mean Girls in Assisted Living. What happens to bullies? Some of them become old bullies.

By Paula Span

When Rhea Basroon’s mother moved into a New Jersey assisted living facility a few years ago,she found a good friend in an new neighbor named Irene. Her daughters, long concerned that their widowed mother had become isolated and depressed, were initially delighted. “She and Irene were inseparable,” Ms. Basroon told me. “Whenever there was an activity, they’d both go.Whoever got there first saved a seat.” The two even discouraged others from joining them: “It was just her and Irene.” Then, disaster. Irene was lured away by another resident, abandoning Ms. Basroon’s mother. “She was so lonely. There was no one else she’d bonded with,” Ms. Basroon recalled. “She was completely devastated.” But wait! The third woman apparently eventually tired of her prize, or perhaps moved on to other prey. “She dumped Irene, and Irene came back to my mother,” Ms. Basroon said. They remained fast friends until Irene’s death several months later. In senior residences, Ms. Basroon concluded, “it’s like junior high, with that cliquishness, that excluding” of others. This phenomenon, a sort of social bullying, apparently comes as no surprise to administrators of senior apartments, assisted living facilities, nursing homes and senior centers. “What happens to mean girls? Some of them go on to be come mean old ladies,” said Marsha Frankel, clinical director of senior services at Jewish Family and Children’s Services in Boston, who has led workshops (innocuously called “Creating a Caring Community”) for staff and residents. What sort of behavior are we talking about? Ms. Frankeland Robin Bonifas, an assistant professor of social work at Arizona State who has begun research on senior bullying, described various situations:
Attempts to turn public spaces into private fiefdoms. “There’s a TV lounge meant to be used by everyone, but one person tries to monopolize it — what show is on, whether the blinds are open or shut, who can sit where,” said Dr. Bonifas.
Exclusion. “Dining room issues are ubiquitous,” said Ms. Frankel. When there’s no assigned seating, a resident may loudly announce that she’s saving a seat, even if no one else is expected,to avoid someone she dislikes. In an exercise class, added Ms. Frankel, who has gathered examples from administrators at several Massachusetts facilities, “one resident told another, in a condescending way, that she was doing it all wrong and shouldn’t be allowed to take the class.”General nastiness. “People loudly and publicly say insulting things. ‘You’re stupid.’ ‘You don’t know what you’re talking about.’” Ms. Frankel said. In a Newton, Mass., facility she observed, a resident actually discouraged her daughter from visiting, because the daughter was obese and her mother didn’t want her subjected to disparaging gossip. Racial and ethnic differences can also set off malicious comments.
Could all this be a consequence of cognitive impairment? Sometimes, Ms. Frankel said. Dementia can lead to disinhibition, and people say things they might once merely have thought.But social manipulation and exclusion seem to have more to do with acquiring power, a feeling of control, at a point in life when older people can feel powerless. (Adolescence is another of those points, of course.)  “Perhaps people don’t have ways to get that sense of control in healthy ways, so it’s done by dominating others,” said Dr. Bonifas, a former nursing home social worker.“It gives them a sense that they’re important.” Some intended victims can shrug off this petty tyranny, but others suffer. They withdraw from activities and social situations, perhaps experience anxiety or depression, want to move out. “It can get pretty nasty, and these are vulnerable people,” Ms. Frankel said.  She hasn’t found her caring community workshops very effective at getting mean seniors to behave better, since nobody considers himself or herself a bully, but they do appear to embolden the staff to intervene. That can make a difference: At a Massachusetts class in conversational English, five of the regulars — all elderly Russian women with scientific backgrounds — turned on a less-educated newcomer from Hong Kong. They rolled their eyes when she spoke, and they sniped in Russian. The instructor, a social work graduate student and former teacher, finally announced that she would not tolerate abusive behavior in the classroom and threatened to end the session the next time it happened. “That worked,” Ms. Frankel reported. But bolstering old people’s ability to stand up for themselves might also work. Dr. Bonifas has undertaken a pilot research program on bullying in two Phoenix senior apartment complexes and has noticed that, as with youth bullies, not everyone is equally likely to be a target. She’s contemplating how to teach someone to say, “You’re not going to treat me like that. Every chair here is available to anyone, and I’ll sit where I want.” That way, she thinks, “the bully doesn’t derive power from the interaction.” Perhaps it shouldn’t startle us that this behavior arises in senior residences — people are people, after all, wherever they live — but I’ll admit to some surprise. We all remember this harassment from the cafeteria, but we’d like to think that people learn something in the intervening seven or so decades, right? “We have expectations that as we grow older we become more mature — the stereotype of the wise old  person who knows how to conduct herself,” Dr. Bonifas said. “That’s not necessarily the case.”