Orientation sessions help families in LTACs

Transition from acute care often difficult to accept

Recognizing that the transition between the short-term acute care hospital and a long-term acute care hospital (LTAC) is difficult for patients and families, Mesquite Specialty Hospital in Dallas has begun weekly orientation sessions to help family members understand what an LTAC is and how the services a patient will receive there are different from what happens in the short-term acute care hospital.

"We think it's important for family members to feel comfortable with the LTAC setting and the care the patients will receive. We hope that the orientation sessions will give them a higher level of comfort with the facility and having their loved ones admitted," says Cathy Campbell, BSN, MBA, CHC, FACHE, director of case management.

The first 72 hours after admission are the most difficult for the family and the patient, Campbell says.

Many of the patients originally expected to be hospitalized and then go directly home. Others don't understand the concept of an LTAC and believe that they are being transferred to a nursing home, she says.

"In the short-term acute care hospital, patients are admitted and discharged very quickly. Our patients are very sick, with a lot of co-morbidities, and they stay for a long time. Families often have a difficult time accepting this," she says.

The orientation sessions are designed to answer the questions and concerns that patients and family members have early in an LTAC stay and to make the transition easier. Information includes the mission and vision of the hospital, what services LTACs provide, the plan of care, and the expected length of stay.

The family orientation session lasts about 45 minutes, with time at the end for questions.

The sessions are not mandatory, but staff encourage family members to come.

The hospital administrator opens the session and presents the hospital's guidelines and the principles of treating patients.

"Business development is involved to educate them on what the plan of care is all about," Campbell says.

Representatives from case management, nursing, physical therapy, occupational therapy, speech therapy, respiratory therapy, and dietary also discuss the services their departments provide.

The orientation sessions are a good way for the staff to get to know the family members and vice versa and to start the communication process, Campbell points out.

"Quite a few of our patients are so sick that family contact is very important. We educate them on what we can do for the patient and make sure that we understand their expectations," she says.

In addition, staff offer individual patient and family conferences in which they discuss the specific services the patient will require, the treatment plan, and the expected length of stay.

"In short-term acute care hospitals, there is no penalty if patients go home early. Federal regulations require that patients in an LTAC have a length of stay of 25 days or longer, and there is a penalty if patients stay less than 25 days," Campbell says.

This means that before patients are admitted, case managers must ensure that they need a 25-day stay to prevent the facility from being penalized for accepting short-stay patients and make sure that the patients and family members know that the stay will be long-term.

"We tell them the expected average length of stay is 25 days. Sometimes they hear and understand this. Other times, they want to leave after 10 days. That means a penalty for us, and it throws up a red flag for CMS," Campbell says.

The hospital's case management department includes one social work case manager and two RN case managers who coordinate care for 40 patients, with each staff member responsible for about 13 patients.

The staff are cross-trained to fill both the case management and social worker roles and work as a team to collaborate on care for the patient.

At Mesquite Specialty Hospital the case management staff are assigned by physician, which enables them to develop a close working relationship with the doctors.

One of the challenges of case management is to educate the physicians that patients must meet medical necessity for an LTAC stay and that an LTAC has to meet regulations for treatment that are different from those in the short-term acute care hospital.

"An LTAC is not an all-inclusive setting. Physicians must focus on the reason that patients are admitted to the LTAC rather than ordering diagnostic work-ups," she says.

For instance, if a patient is admitted to an LTAC for ventilator weaning and is exhibiting symptoms that could indicate some type of cancer, it's not appropriate for physicians to order a test to determine if the patient has cancer.

"Our concern is to take care of the condition that brought the patient to the LTAC in the first place. Tests that typically are done on an outpatient basis are not appropriate in an LTAC. If we find the patient has cancer, we can't treat it here. The doctor needs to wait until the patient is stabilized to have the test and then go from there," she says.

The case managers work closely with the physician to make sure that the tests and procedures they order are appropriate in the LTAC setting.

If the case manager feels a particular procedure isn't appropriate, he or she calls the physician and asks if the test or procedure is necessary at this time or if it could be completed after discharge.

"Our concern is taking care of what the patient is hospitalized for. If it's a serious and life-threatening situation, we send the patient to a short-term acute care hospital. If it is a diagnostic work-up, it should be done on an outpatient basis after the patient is discharged," she says.

The case managers work with the physicians to eliminate duplicate tests and procedures.

For instance, if a physician orders an echocardiogram and the case manager reviews the chart and determines that the patient had the procedure four days previously at the acute care hospital, the case manager gives the doctor the results and asks if the patient needs a repeat procedure.

"Our case managers are attuned to what tests and procedures the patient had at the previous hospital, and often the doctor doesn't know," she says.

When Mesquite Specialty Hospital gets a referral, the LTAC's liaison visits patients in the short-term acute care hospital, determines if they are appropriate for admission, talks to the patients and their families about what will happen during an LTAC stay, discusses the LTAC's two areas of expertise — ventilator weaning and wound care — and shares the hospital's outcomes data with the family.

The LTAC staff review the paperwork for medical necessity and to determine that the patient can benefit from a stay.

Staff reviewing the file include the case manager, nursing director, respiratory therapy, physical therapy, and pharmacy.

"The clinicians review the chart to see if we need any more information or test results, and the pharmacist makes sure we have the drugs they need," she says.

Since the LTAC is subject to scrutiny from the Recovery Audit Contractors and other CMS auditors, making sure that patients meet medical criteria is a must, Campbell says.

In order to meet medical necessity for admission to an LTAC, patients must be too sick to go home or be transferred to a skilled nursing facility, Campbell says.

"All of our patients have high-level needs. They aren't ready to go home after a short stay. The acuity and severity of the patients is much higher than in a regular hospital," she says.

Most patients have been in the intensive care unit at the short-term acute care hospital. They stay at least 24 hours in the ICU at Mesquite Specialty Hospital. Then they are moved to the high-level observation bed that is on the medical-surgical unit but close to the nursing station. Nurses who work on the high-level observation unit have a caseload of just three patients.

The case managers see patients the day after admission and conduct a thorough assessment, including determining the patients' expectation for the stay.

The team reviews every patient in the hospital once a week, identifying barriers to recuperation and barriers to discharge. They look at whether the patient is likely to go home or will need another level of care after discharge from the LTAC.

The case managers call the families after the team conference to let them know the patient's condition and any changes in the care plan.

"We manage the whole concept of the patient's care. We manage the patient every day, making sure that everything happens in a timely manner and is appropriate for that particular patient," she says.

The names of everyone caring for the patient are on a magnetic board in the patient's room.

"Everyone knows who the case manager is, and if something comes up or they have questions, they know who to talk to. The case managers work closely with the patient advocates who answer complaints and concerns," she says.

As the case managers make arrangements for discharge needs, such as home health or durable medical equipment, they counsel the family about what will be best for the patient.

"It's not always what the patient and family want to hear, but we always communicate what is safe for the patient. The expectations for patients can change every few days. They may be improving but then have a set-back. We stay constantly in communication with the family so they know what to expect," she says.

(For more information contact:

Cathy Campbell, BSN, MBA, CHC, FACHE, director of case management, Mesquite Specialty Hospital, e-mail: cec5479@yahoo.com.)