Q: When should physicians begin thinking about skilled nursing and rehabilitation services for older persons admitted to the hospital?

POMPEI: As soon as the patient comes into the hospital. Discharge planning should be part of the admissions process.

Q: What do physicians need to keep in mind when they want to send their patients to the SNF?

TISNADO: The physicians need to proceed with a discharge from the hospital as if the patient were being discharged to home. Then, the patient is readmitted to the SNF.

Q: Who are most of your patients?

TISNADO: We have a pretty large volume of orthopedic surgery patients -hip fractures or total joint replacements - and vascular surgery patients, including amputees. Of course, we also have many general medicine patients. We keep in mind that almost all our patients are elderly with numerous needs - multisystem problems - that go beyond their admission diagnosis. A few patients, on the other hand, may have been incredibly active until a single incident sent them into the hospital and then here.

POMPEI: Orthopedic patients offer a teaching challenge. They need to learn how to function with a new or revised joint, for example. We work with all of our patients to achieve specific functional goals - to go up and down steps, to prepare a meal, to transfer safely from a wheelchair to a commode. Most patients continue their recovery at home with a home care referral.

Q: Who usually attends patients on the SNF?

POMPEI: Sometimes it's the patient's primary care doctor. We're conveniently located for physicians who regularly make rounds on the acute care units. For patients who have had surgery, the surgeon will want to continue to provide care while the patient is on the SNF. Sometimes the care will be assumed by a rehabilitation physician or, less often, by me, particularly if the patient is from out of the area.

Q: What about cost?

TISNADO: We're going through a transition. We were reimbursed at 100 percent of cost for the first four years - that's standard, I understand, for a start-up unit. Since Sept. 1 we've been getting a per diem rate from Medicare, so our reimbursement will be parallel to community-based facilities. Our acuity tends to run a little higher than typical community units.

Q: Are you an alternative to a freestanding nursing home?

TISNADO: Often, we are a convenient alternative to transferring a patient to another location, but this unit is not designed to be a long-term care facility. Our patients typically are making the transition from acute care to their homes. Often, patients heading from acute care to a long-term care facility are assisted in a direct transfer by the case manager. Patients who live out of the area often select a facility nearer home for long-term care.

POMPEI: Before this unit was established, patients were referred to freestanding nursing homes, but then they often needed to stay in acute care units longer, which can be costly. I think most of our physicians have a lot of confidence in discharging patients to our on-site SNF earlier than they would to a freestanding nursing home.

Q: Isn't it unusual to operate a SNF that is limited to Medicare patients?

POMPEI: It may not be common for freestanding facilities, but I don't think we're unique among hospital-based SNFs.

Q: Can you say a bit more about how case managers and physicians work together?

POMPEI: I think it's really crucial that physicians take advantage of the discharge planning services of the case manager. They can identify when a patients have functional deficits that would impair their doing well at home. While the physician may focus on medical issues and long-term health, the case manager will be evaluating such practical issues as whether the patient can cook, go to the bathroom or get dressed. If it is apparent that the patient will not recover or be independent in any way, or even successfully return to his or her board and care, then long-term skilled nursing placement should be considered. Also, referring physicians understand their patients' long-term needs, and it's important that they make these known when patients arrive.

Q: What should physicians be looking at when they evaluate their patients for discharge placement?

POMPEI: This has changed in recent years. We look at this issue a bit differently from an acute medical or surgical unit. Placement hinges on function more than on symptoms. We keep in mind that functional abilities can be impaired as much from treatment - at least temporarily - as from disease.

The key test is whether the patients who are functionally unable to do what they were previously able to do have a chance for recovery, then a SNF is a place for them to restore their functional status.

Q: How often do your patients go back to acute care?

POMPEI: It's not very common. But patients have an advantage in a place like this, located next to acute care units.

Q: How are your patients different from those of the CIRU?

TISNADO: The CIRU's focus is acute rehabilitation. The criteria for that unit is the ability to tolerate three hours of therapy per day. Patients must be able to participate and demonstrate measurable gains to stay with the program there. Here patients may receive two to three hours of therapy per day but progress at a much slower rate, which is OK.

POMPEI: Both units serve an elderly population with functional limitations, so there is some exchange of patients.

Q: What sort of programs do you offer patients?

TISNADO: The program has a very effective interdisciplinary team of professionals that works well together. We have a case manager who evaluates home care needs and a social worker who evaluates and assists with psychosocial needs. A chaplain deals with spiritual issues; a dietitian looks at nutrition needs. We have a recreation therapist who looks at their former lifestyles and what they like to do for recreation. Here on the unit, patients may carry out activities in their rooms or they may join one of the regularly scheduled group activities posted on the activities board. We have tours of the hospital gardens, "trips" to the Bing Music Series, and jewelry making, to name a few. An observer would notice that we encourage patients to dress and to eat their meals in our dining area.

POMPEI: We have a dedicated staff of physical and occupational therapists, as well as a speech/language pathologist. This group of professionals focus on the unique rehab needs of our elderly patients. They also provide patient/family teaching to prepare patients for going home, as well as ordering any special equipment they might need. Our nursing assistants are cross-trained in rehabilitation techniques so that they can enhance the physical therapy program.

TISNADO: The therapy staff can delegate tasks to the nursing assistants. These activities, such as such as assisting a patient with ambulation, are things the nursing assistants do anyway, but here they may spend concentrated time on a specific activity. Nursing assistants might work with a patient in transferring in and out of a bed. In another unit a nursing assistant would routinely help a patient go to the bathroom, but here the nursing assistant will work with the patient to do it more independently. It might take more time, but it facilitates the patient's progress.

TISNADO: Three days a week we have interdisciplinary team rounds. Team members talk about the progress of a patient and plan what needs to be done.

Q: What special accommodations do you make to work with the elderly?

TISNADO: The nurses here know to look for such things as cognitive deficits, incontinence issues, consequences of poor eyesight or hearing. For example, they may take the time to make sure that someone has a larger-print book. They need to be generalists.

POMPEI: It's not often that we can fix or cure the cause of functional decline in older persons. We recognize and attend to cognitive impairments, depression, mobility problems, etc.

Q: What about medication?

POMPEI: We're very attentive to medication dosages, numbers, drug interactions. We have a very active pharmacy group that works with us.

TISNADO: At Stanford's SNF, we really try to avoid overreliance on medication and try to find better ways to cope with our patients' cognitive changes. At its worst, in some settings, nurses might deal with confused patients by getting a physician to order medication to quiet them down. In reality the drug often just perpetuates the behavior.

POMPEI: We're highly regulated. The government has imposed restrictions on the use of so-called chemical constraints. We support these regulations, and we are constantly vigilant for adverse drug reactions. We review the medication list regularly with pharmacy at interdisciplinary team meetings looking for problem areas, duplication, overlap, etc.

Q: What are some alternatives to medication?

TISNADO: Sometimes if you've got a patient who is agitated or confused, it is helpful to provide some form of diversional activity. The recreational therapists can play a role in this. Some of the activities available include listening to music, playing cards or other games, participation in arts and craft projects, etc.

Q: What role do cultural factors play?

POMPEI: We do have a culturally diverse population. Being knowledgeable about cultural norms and personal preferences is a regular challenge.

Q: What about long-term trends for the SNF?

POMPEI: Many national projections show that as the number of hospital beds declines, the number of long-term care beds will increase substantially and eventually exceed the number of acute care beds. I think hospital stays in acute care will continue to shorten, but some people are simply not going to be able to get well in two or three days, or to be cared for at home after two or three days of acute care. So a transitional care unit like this may allow more time for them to regain their functional abilities. It may also help avoid a long-term care placement.

Q: Anything else you'd like to say about the SNF?

POMPEI: An important goal of our unit is to help people return to their optimal levels of function and continue their lives with the best quality possible.

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