Realistic recovery: skilled nursing providers must keep patients hopeful yet realistic about their goals

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MedPAC recommends reforming Medicare payment system for skilled nursing facilities
MedPAC recommends reforming Medicare payment system for skilled nursing facilities
When it comes to rehabilitative care, skilled nursing providers must perform a delicate balancing act. Not only do they have to keep rehab patients optimistic about their progress, they also must stay focused on setting realistic goals and committing to prudent, not rushed, discharge planning.

Simultaneously meeting those goals has become increasingly challenging for skilled nursing operators. They are caring for higher acuity patients today, which can delay rehab progress–and, in some cases, lead to premature discharge based on the assumption that a patient isn't responding well to therapy. Providers are also facing reduced reimbursement and budget cuts. In some cases, this is making it increasingly difficult to employ and retain quality therapists, and embrace new rehab technology and modalities.

“The discharge to home or to a lower level of care is still too low in some skilled nursing facilities and markets,” notes Robert Levin, CEO and president of Covenant Care LLC, a skilled nursing and assisted living provider based in Aliso Viejo, CA. “The key challenges in getting residents to their highest functional level and safely discharged to a lower level of care or home are setting mutually agreed upon goals early, and having the staff and the equipment to get the job done.”

Establish goals early

Among the first steps toward successful rehabilitation, sources say, is working directly with the patient and family members as early as possible to set realistic therapy goals and develop a discharge strategy. Any plan should take into consideration a wide range of factors, including the patient's overall condition and the therapy interventions available.

“First we need to stabilize, then rehab,” stresses Levin. “We meet with the patient and their family within the first 72 hours, after nursing, therapy and social services have done a complete assessment and care plan. At this meeting, we discuss our plan and answer questions.”

He says it's critical to establish goals, time lines and objectives at this meeting, and also have an understanding about what the discharge environment will be and what the patient will be required to do in that environment (such as home activities, meal prep, and so on). “This process is critical in getting everyone's interests in alignment,” he emphasizes.

Preliminary meetings also provide an effective forum for discussing unrealistic discharge expectations that may have been set by physicians. Often, physicians indicate to families that the patient will need to be in a nursing home for several weeks when, in reality, that time frame is far too brief, explains one rehab specialist.

“The facility's ability to communicate a more realistic time frame to the resident and family as soon as possible upon admission is extremely important,” explains Rick Starke, vice president of client services for Accelerated Care Plus, a provider of specialized rehabilitation programs for long-term care operators and rehab service providers.

Step by step

Providers also are finding success by focusing on smaller, more tangible goals, as opposed to focusing strictly on the discharge itself. Virginia Mennonite Retirement Community in Harrisburg, VA, considers smaller goals, such as a patient's ability to walk a short distance or perform small transfers, often known as “windows of independence.”

“Rather than a black or white or independent/dependent labeling, our therapists and nursing staff identify skills and goals to encourage manageable gains on the road to full independence,” says Melissa Fortner, vice president of long-term care and assisted living care at VMRC.

To further motivate patients and promote progress, VMRC's rehab staff works with patients' families to provide education and help them assist with transfer training and other tasks—an approach that promotes family participation and patient independence, according to Betsy Peake, manager of EnduraCare Rehab at VMRC.
At Jewish Home Lifecare/Sarah Neuman Center in Mamaroneck, NY, therapists pursue key information about the patient and their lives before their impairment to help them formulate an individualized therapy strategy.

“About 99% will say their goal is to go home, but when that's their only goal, it can be frustrating and discouraging if it doesn't happen as quickly as they had hoped. While we still focus on that big goal, we take it a step further by asking what they did at home that they're missing the most, such as cooking or playing the piano,” says Susan Achambault, director of Rehabilitation Services at Jewish Home Lifecare/Sarah Neuman Center.

“When you discover their interests, you can make a more personal connection. You can then use those unique interests to motivate a patient by giving them smaller goals and milestones to celebrate along the way,” she says.
Setting smaller goals helps serve a dual purpose. Because some rehab patients may never be able to return home, it's essential that they still focus on physical gains, while also realizing that they don't have to give up everything they enjoyed at home.

“We assess their progress and have a dialogue [about discharge] about two weeks in. While many do go home, some will not. That's a difficult conversation to have, but also an important one,” notes Archambault. “If it doesn't look like they will be able to return home, we then provide them with their options and begin [delicately] introducing them to the idea that this will become home.”

Plugging into technology

Like other care segments, specialized equipment and technology is playing an increasingly important role in the realm of rehabilitation. When applied appropriately, it can help certain patients heal and build strength more quickly, and reduce pain, which can allow them to participate in more aggressive therapy sooner.

“Hospitals are discharging patients as quickly as they can,” says Chris Castel, Ph.D., ACP's co-founder and chief science and technology officer. “Today, our residents are more acute and still in the early healing phases. They may have a number of co-morbidities that make aggressive early rehab interventions difficult.

He points out that it's difficult to exercise a post-operative knee patient, for example, if a therapist can't even touch the area because of excessive pain and swelling.

When used early in the sub-acute stay, interventions, such as electrotherapy and shortwave diathermy, can reduce pain and edema, and pave the way for faster rehab intervention and recovery, Castel adds.

Another noteworthy plus? “Reimbursement covers this expense under the RUG system, as therapy minutes provided as a skilled service,” Castel says.

Advanced modalities play an essential role in Covenant Care's therapy program.

“We could not achieve the kinds of rehab results we get without our modality and exercise equipment,” stresses Levin. All Covenant Care facilities use e-stim, diathermy and ultrasound equipment from ACP, and they rely heavily on the vendor's ongoing training and program enhancements to drive success. Despite taking in higher acuity patients today, Levin said 50% or more of all Covenant Care rehab admissions return safely to home or a lower level of care.

Providers also are relying on more entertainment-based computer technologies to delivery therapy in a fun, creative, yet challenging way. One provider is It's Never 2 Late, of Centennial, CO, which offers specialized computer systems for the senior care setting. Provider users can increase reimbursement, while creating an engaging, personalized therapy experience for patients, says Lori Snow, IN2L's director of sales and marketing.