Go the extra mile with subacute care pathways

Pass government muster with emotional care

If your facility has a subacute unit, you’ll need to go the extra mile with your clinical paths to satisfy Medicare surveyors, says Pat Maben, RN, MN, director of adult home care programs at the Kansas Department of Health and Environment in Topeka.

"We want to see an emphasis on the patient’s quality of life — of dignity, autonomy, and involvement [in their care]," she says. "We want subacute providers to look at the patient as a total person and meet his or her unique needs."

That means creating pathways that encompass more than physical recovery.

Ranking psychosocial needs

For example, at a 17-bed subacute unit at Overland Park (KS) Regional Medical Center, an interdisciplinary team developed a pathway for terminally ill patients that includes the five stages of grief. Members included representatives from physical, occupational, and activity therapy, social services and dietary departments, and subacute and clinical education nurses.

The path prominently lists these stages in the left-hand corner of the pathway to remind team members to daily document the grieving for the patient and family members, says Martha Hudson Ramsey, RN, MS, unit manager. The stages of grief — denial, anger, bargaining, depression, acceptance — were formulated by psychologist Elizabeth Kubler Ross, PhD, in her ground-breaking book, Death and Dying.

Other early steps in the path, which Maben praised, include the discussion of advance directives, hospice, and self esteem.

Self-esteem, for example, is tracked by asking patients to rate how they feel about themselves on a scale of 0 to 10.

Other psychosocial needs are also ranked:

1. Potential for disturbance in self-concept as related to illness;

2. Knowledge deficit related to tests, procedures, and disease processes;

3. Potential need for assistance with home care planning;

4. Potential need for assurance with home care planning;

5. Potential for injury as related to unfamiliar environment;

6. Alteration in comfort as related to disease process;

7. Grieving related to loss of control over life, body function, changes in self-image, and impending death;

9. Potential alternative in respiratory status as related to disease systems;

10. Impaired general strength and endurance as related to illness.

Team members take this information to interdisciplinary care meetings where family members are invited.

"This is where we sometimes get quality of life concerns we don’t expect. The concerns may seem totally off the wall, but they must be addressed," says Ramsey.

She cites the example of an elderly man who had a stroke and was not sleeping because he was afraid of being unable to wake up after his stroke. "After discussing this problem with the team and the family member, we had the chaplain visit and read a scripture on fear," she says.

Because subacute patients often have more than one diagnosis, the team developed supplemental paths in addition to the primary ones.

"If we have a terminal patients who also has a stage I wound we would acknowledge [that] the patient has the wound, but that’s not the primary reason he or she is here," she says.

Yet, wound care must be addressed. "We must show evidence of acknowledging and treating the secondary diagnosis to the surveyors."

Incorporating such psychosocial needs in the path not only satisfies surveyors, it’s good business sense, says Maben. "It helps ensure good outcomes. That’s the name of the game."