Report puts subacute care under the microscope

9 recommendations offered for subacute providers

The Nursing Home Community Coalition of New York State in New York City conducted an extensive study of subacute care problems identified by New York nursing home providers and consumer advocates nationwide.

The January 1997 study, called Subacute Care in Nursing Homes: Consumer and Provider Perspectives on Benefits and Concerns, was funded by several New York City-based organizations and the New York State Legislature. The Robert Sterling Clark Foundation, The Altman Foundation, and The Jean and Louis Dreyfus Foundation all contributed to the survey. It makes the following recommendations for regulating subacute care:

Nursing facilities should be required to assess subacute residents within the first week of the resident’s stay.

The report defines short-term residence as those who are expected to be in the facility for fewer than 100 days. Specifically, the coalition recommends nursing facilities be required to:

— assess subacute residents once a week for the first two weeks of stay;

— assess patients once within the next two weeks;

— assess patients once a month for the next two months.

Nursing facilities should be required to develop, with participation of residents and family, goals with time lines for meeting them.

— Nursing facilities should be required to develop, with participation of residents and family, a tentative discharge date for those residents who expect to go back home.

Nursing facilities should be required to provide a more intense number of skilled-nursing hours for those residents than they do for traditional residents.

"We believe it should be four to five hours a day for subacute care, and right now it’s three to four hours a day for traditional residents," says Cynthia Rudder, PhD, director of the Nursing Home Community Coalition and the author of the report.

Rudder says these recommendations are based on what providers say is needed.

Transfer/discharge regulations must include requirements for written notice of a state health department external resident appeals rights for short-term residents and family when there is a disagreement with the facility regarding inability to meet goals and benefit from more therapy.

That right is already in place for New York state nursing home residents, and the coalition is recommending it be expanded to include subacute residents. Specifically, the coalition suggests:

— The resident and family must be given enough time to appeal before discharge.

— Residents must be allowed to remain in the subacute bed and in the facility until the appeal decision is rendered.

— This protection must be in place regardless of whether the individual’s care is reimbursed by Medicare, Medicaid, insurance, or by managed care companies.

If an appeal determines that the resident still needs subacute care, but all benefits for such care have run out and the resident is not eligible for Medicaid, the maximum amount that the nursing home may charge is the rate they were previously receiving.

The activities should meet the needs of the short-term resident, just as the regulations require for long-term residents.

The coalition recommends that nursing homes continue to assess recreational needs of all residents, including subacute care patients. "But we agree with providers that they shouldn’t have to do as many assessments and [as much] paperwork for the short-term person," Rudder says.

Instead, she adds, perhaps there should be one simple assessment of the subacute patient’s recreational needs. "Do the assessment; find out what’s needed, and then you do it," she says.

If the assessment shows that the patient is busy all day with therapy and is too tired for recreational activities, then probably no recreational activities need to be scheduled.

Short-term subacute programs should be required to conduct evaluations of the success of their programs in meeting the goals they set for their residents.

The coalition states that these outcome measures and results should be made public and that the federal government should fund studies and research into finding appropriate evaluations and outcomes that would satisfy providers and consumers.

Physicians who specialize in the specific medical problem being treated must be active members of the care planning team and be available for care and information.

The physicians should see residents frequently, sometimes as often as weekly, the coalition recommends.