Skilled Nursing Facility
It's a common clinical situation: A patient no longer requires acute care, but isn't quite ready to function effectively at home either. This problem is becoming increasingly common as the percentage of older adults with functional limitations increases on our hospital units. Fortunately, Medicare will pay for the services of a Skilled Nursing Facility (SNF), which at Stanford University Hospital is located on C-2. This month FACT FILE talks with Peter Pompei, pictured below on right, SNF medical director and associate professor of medicine, and Julie Tisnado, at left, SNF nurse manager.

1. The 22-bed SNF opened in October 1993. Because of licensing restrictions, it serves an exclusively Medicare population. The unit provides interdisciplinary services, including short-term rehabilitation, for the largely octogenarian and older population. Treatment focuses on realistic goals set by patients and their caregivers.

2. SNF staff include Tisnado, who also serves as nurse manager on the Comprehensive Inpatient Rehabilitation Unit (CIRU), and Pompei, a full-time faculty member who works 10 percent time on the SNF. Other staff members include two assistant nurse managers, one nurse educator, 14 staff nurses, 16 certified nursing assistants, one licensed vocational nurse, four unit secretaries and three support services assistants.

3. The average age of patients is about 85, although the unit cares for Medicare- eligible patients of all ages. About 80 percent of SNF patients return home; 20 percent are admitted to long-term care facilities.

4. The SNF is an exempt unit, meaning patients are first discharged from acute care services and then readmitted to the SNF. They must meet Medicare criteria for admission, including at least three days on an acute care unit. SNF stays are limited to 100 days and average two weeks. To date no patient stay has exceeded 90 days. Special procedures and regulations apply to the SNF. Here are some highlights from the convenient SNF information card that the unit makes available for physicians:

  • Physician signatures are required on a number of forms, including the certification form, weekly drug regimen review, consents for physical and chemical restraint, and rehab therapy order stickers.

  • The exact dose of each medication must be specified. Dose ranges are not allowed. Antibiotic indications and durations must be specified. Specific instructions must be written for bowel care.

  • A TB screening is mandatory.

  • Every attempt is made to limit the use of physical restraints. Posey vests and soft wrist restraints may be acceptable, and orders for any restraint must be reviewed and renewed every 24 hours.

5. Tisnado, a Stanford employee since 1981, received her bachelor's degree in nursing from California State University at San Jose in 1982. She received an MS in nursing with a major in nursing administration in 1990 from UCSF. Tisnado joined management in 1987 as assistant nurse manager of B3 (neurosurgery). She has been nurse manager of the CIRU (C-1) since June 1993. In March 1994, the SNF was added to her management role.

Pompei became medical director of the SNF shortly after he joined the Stanford faculty in October 1993 from a post as associate professor of clinical medicine at the University of Chicago. He is a 1977 MD graduate of the University of Chicago's Pritzker School of Medicine. He completed a residency in internal medicine in 1983 at the University of North Carolina, Chapel Hill. In addition to his SNF duties, Pompei serves as director of graduate medical education and associate director for clinical programs at the Geriatric Research, Education and Clinical Center at the Veterans Affairs Palo Alto Health Care System.

6. Phone number for the SNF unit is (650) 723-5236.

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