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How nursing homes are filling the gap in continuity of post-acute care

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Mohammad Fattal, M.D.
Mohammad Fattal, M.D.

Dispelling a myth, changing a perception and instigating a cultural transformation is a heavy lift and takes a lot of time. But all of those things are taking place in nursing homes across the country, even amidst challenges of a nursing shortage, low wages for long-term care employees and a burgeoning elderly population that is living longer and with more complex health conditions.

Yet many skilled nursing facilities are venturing forth with smart strategies that better serve seniors' healthcare needs and have become safety nets for gaps in the healthcare system where patients often fall through. 

Developing specialty care units in the long-term care setting is strengthening the transition process from hospital discharge to the next care stop.  

A perfect example of this is in Northern Kentucky where a nursing home identified a hole in pulmonary care and filled it. In a very short time, re-hospitalizations have gone down and patients have experienced less upheaval and more continuity as they re-learn movements and activities during a gradual rehab process tailor-made for their state of health following discharge.

Many times, these pulmonary patients are not ready for intense therapy and need to gradually regain the stamina to ease back into daily life routines.  They need an “in between” if you will, for rehab.  If a patient can't handle walking more than 20 feet, they need a phased-in approach and the long term care setting can provide that to them.

Shortness of breath and low levels of oxygen in the blood  – from conditions like Chronic Obstructive Pulmonary Disease, asthma, chronic infections or pneumonia – rob patients of their independence, quality of life, and result in frequent hospitalizations. Difficulty breathing is life-altering, life-threatening – not to mention a terrifying sensation that these individuals experience on a constant basis.

As a physician concerned with the total health care of the individual and one who integrates the biological, clinical, and behavioral sciences when treating patients, I've seen firsthand how devastating and life altering these conditions can be for those afflicted. And it's a problem that is not unique to just our area. 

It's also expensive. Nationally, conditions like COPD and asthma resulted in $60.8 billion in healthcare expenditures and lost productivity. Pneumonia and COPD are the third and fourth leading causes of hospital readmission for Medicare patients – costing the program millions each year. 

In Kentucky, we have one of the highest rates of smoking in the country, and nearly 10 percent of the state's population has been diagnosed with COPD. Nearly a quarter of Kentuckians with COPD reported a hospitalization or emergency department visit in the past 12 months, and almost three-quarters say that shortness of breath impacts their quality of life. 

How do we address such staggering statistics that represent living, barely breathing individuals?

Led by a team of physicians, respiratory therapists and a specially trained nursing staff, the “Breathe Again” pulmonary rehab program at Woodcrest Nursing & Rehabilitation Center aims to tackle this troubling health condition.  

Breathe Again is a two-phase process that first reduces oxygen dependence and increases activity tolerance and secondly, rebuilds strength to achieve the highest level of independence as possible. This latter phase focuses on discharge planning and preparing patients for life on their own and includes education on disease management and lifestyle changes. 

Throughout their stay patients engage in pulmonary strength-building activities geared toward increased activity tolerance and endurance. The state-of-the-art-equipment of a unit-wide air purification system allow us to aggressively tackle some of the variables that can often delay improvements in respiratory function. 

What is unique about this level of pulmonary rehab being offered in a skilled nursing setting?  The nursing facility is the critical stopping point between the hospital and the community.  We are the essential cog in the wheel because our setting can offer the range of pulmonary rehab for patients at any end of the spectrum following hospital discharge. This promotes a continuity of care that enhances health outcomes, reduces re-hospitalizations, eliminates the back and forth with various providers that patients often find themselves having to navigate while in a compromised state of health, and assists in follow up with the pulmonologist. 

Breathe Again is a vital part of a healthcare continuum for patients struggling to accomplish what most of us take for granted - taking that next breath.

The adage, “this is not your grandmother's nursing home,” has never been truer.  Many nursing homes are providing sophisticated levels of care and rehab, training staff to develop expertise in targeted areas of care and closing the gap in a health care system often rife with chasms.   

This trend should make us all breathe easier.

Mohammad Fattal, M.D., is the Medical Director for Woodcrest Nursing & Rehabilitation Center in Elsmere, KY.

Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.