Rehab: The new math of LTC

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Rehab: The new math of LTC
Rehab: The new math of LTC
A move toward serving higher acuity patients is not a decision to be taken lightly. It means raising the bar considerably for skilled nursing facilities, requiring increased infrastructure investment, hiring additional clinical staff and making dramatic operational changes, rehab specialists say.

In the past, some SNFs have opted not to go the high-acuity care route, for various reasons. But with more high-acuity patients entering the long-term care environment than ever before, this new reality is causing SNF administrators to take a closer look at what's involved with this more sophisticated and demanding resident base.

“I don't think you have a choice anymore,” says Lou Ann Soika, senior vice president at Kennett Square, PA-based Genesis Rehab Services. “We consistently find acuity rates rising in independent and assisted living. This in turn cuts into the SNF admissions. I do believe that if you, as a SNF, don't swim upstream to embrace the more complex patients, you will find yourself at the bottom of the list for hospitals' admissions. Pay-for-performance is going to impact the hospitals as well as the SNFs. We already see hospitals searching for partners who they know provide quality care and great outcomes.”

Soika recommends providers pursue high-acuity patients only when they can provide measurable, documented clinical outcomes, effective chronic disease management, on-site clinical interventions to avoid unnecessary emergency room visits and clinical care proficiency to meet the demands of the more complex treatment needs of the patient.

“It's a given more skilled nursing facilities will want to position themselves to admit high-acuity patients,” says Mark Besch, vice president of clinical operations for Delafield, WI-based Aegis Therapies, a division of Golden Living. He cautions, however, that “there are a number of things to consider before making this move.”

Aegis and its parent company  are committed to providing the right care and services to each new patient in all of their locations, Besch says. But before taking this step, leadership had to determine if the volume of inquiries they received could support the idea. Aspiring facilities also should examine the potential diagnostic profiles of admissions and ascertain whether the facility and rehab teams can care for these patients appropriately, he says.

“The worst thing that a SNF can do is to try to accept a different profile of residents without being equipped to manage their care—whether because of a skill set issue or an equipment issue,” Besch says. “Ensuring that appropriate training and equipment is in place will result in smoother care transitions for patients.”

Sharpening skills
Specific to rehab, Besch points out that patients with pulmonary or cardiac diseases are common diagnostic groups and that SNFs need to position themselves to support these higher acuity patients.

“Therapists need to understand the disease process at a basic level, as well as how they should approach delivery of care differently for these patients compared to those who are not as medically complex,” Besch says. “For a therapy provider, this means making sure that therapists have the appropriate skills to monitor high-acuity patients and understand which signs and symptoms may be associated with patients' clinical conditions. Therapists also should collaborate with their clinical partners in the SNF.”

Rehab management consultant Shelly Mesure agrees that providers must significantly and firmly bolster training in order to accommodate high-acuity patients.

“While all clinicians, including nurses and therapists, are trained to work with all levels of patients, many clinicians do not always possess the clinical competencies required to truly meet the needs of these patients,” says Mesure, president of Philadelphia-based A Mesured Solution. “In many situations, nursing facilities refuse to admit these residents because they cannot provide adequate support.”

Mesure recommends that SNF administration assess the clinical strengths of the nursing staff to find out who has experience in working with high-acuity residents.

“This would be a good step in identifying the amount of on-site and off-site training required,” she says. “Also, the facility's infrastructure may promote or inhibit the ability to increase the number of private rooms. When assessing the number of open beds, compared to higher RUG rates, converting semi-private rooms into private ones may actually be a more sound business decision.”

The RUG-IV incentive
Due to higher reimbursement, caring for high-acuity patients yields potentially greater revenues for a provider organization under RUG-IV. While this financial incentive may spur some SNFs into the rehab realm, they should be aware that internal costs are higher as well, Soika says.

“Although the $500-plus rates seem attractive, you might get a patient who requires $1,200 to $1,500 per day in care costs,” she says. “So the rates are better, but providers have to remember that they have additional expenses, such as increased staffing and paying for therapists and nurses who want to work weekends. There are additional costs for medication, social services, physician consults, and of course, food. Having more patients treated individually translates into more bodies, longer hours and driving more efficiencies without sacrificing patient or business partner satisfaction.”

Mesure adds that the higher RUG rates have not convinced the majority of SNFs to create ventilator units.

“Facilities are intrigued by these rates yet continue to refuse tracheotomy patients and won't consider establishing vent units,” she says. “Adding a vent unit is very complicated, however, and accommodating tracheotomy patients requires proven clinical competencies from nursing and supportive staff.”

Concern that a greater number of high-acuity patients could result in a bad grade from the government's Five Star rating program may be behind some facilities' reluctance to accept them. But Mesure argues that it should not be a factor in the decision.

“At this time, the Five Star rating system does not directly impact any financial reimbursement from Medicare,” she says. “Some entire regions of the country have exactly the same rating across the board under the Five Star system. Although these complex patients will require increased care, proper documentation and staff education should reduce any negative impacts.”

Training, teamwork & tools
Golden Living and Aegis Therapies have been serving high-acuity patients for several years and Besch credits several factors — including training, teamwork and tools — for their success.

Regarding training, the organization's newest program focuses on helping nurses and nursing assistants more effectively care for patients with congestive heart failure, in part with realistic studies that help prepare clinicians for real-life interventions. The teamwork factor, Besch says, emphasizes the critical role of RNs and the interdisciplinary coordination that is required by the high-acuity patient population.

Golden Living also is adding pharmacists to its interdisciplinary clinical teams. Golden Clinical Rx Solutions is an internal consulting pharmacy service company that will review patients' medical records before the individual is admitted to a facility. It will work closely with other clinicians to monitor medications and conditions.

Bolstering information technology systems to integrate and share data is also essential to running a proficient high-acuity program, Besch says, pointing to Golden's adopting Microsoft's Amalga Unified Intelligence System.

“Golden Living is the first post-acute care organization to adopt this data management system, which is used in some of the country's most advanced hospitals,” he says.

Getting ‘progressive'
Soika contends that the more progressive nursing homes have been dealing with high-acuity rehab cases with chronic comorbidities for many years. Over time, they have made the financial commitments and developed the service levels necessary for this special population, she adds.

“The rising acuity level across the long-term care spectrum is causing providers to not only spend money on their physical plant by creating separate and distinct units that rival the amenities of most hotels, but they have also invested time in educating and recruiting the best talent to work on their new medically complex or rehab specialty units,” she says.“These organizations have trained the nursing and rehab staff on how to handle the clinical protocols that physicians and surgeons demand while emphasizing that staff needs to understand that this population requires a ‘service attitude.'”
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