Don’t leave home without it: Subacute a reality for nursing home residents

Idea is to discourage hospital transfer when same services offered at SNF

Medicare’s required three-day hospital stay for residents of skilled nursing facilities (SNFs) may be dumped in favor of providing subacute care for appropriate patients at SNFs, if a pilot program proves cost-effective.

That’s what the Baltimore-based Health Care Financing Administration (HCFA) is aiming for with a Medicare demonstration project in conjunction with Blue Bell, PA-based United HealthCare. Although United HealthCare’s project — called EverCare — originally started as a community effort for enrollees in Minneapolis, the program was expanded last year as a HCFA demonstration project to include sites in Atlanta, Baltimore, Boston, Phoenix, and Tampa, FL. (To see how one site recently implemented its program, see the related story, p. 3.)

The goal is to see if offering subacute services in the patient’s familiar surroundings of the nursing home is more cost-effective than the traditional three-day required hospital stay followed by subacute care, says Marcia Tinsley, business development manager for the Baltimore branch of EverCare. "Right now, there’s not enough data or experience with patients requiring subacute care, but that’s one of the areas the project is looking at to see if having the nurse practitioner involved benefits patients," she adds.

The first important step in implementing the EverCare program was to add the nurse practitioner to the nursing home environment to serve as a case manager and physician extender, notes Judith W. Ryan, PhD, CRNP, clinical director of the EverCare program in Baltimore. "You might not have a large patient group requiring subacute care at any given time, but the nurse practitioner is there to provide services not normally conducted in the home, such as having a blood gas drawn or additional technical monitoring following surgery," she adds.

Involving nurse practitioners in the patient’s care and providing needed subacute services might be the key to keeping patients in the rooms, says Steve Miller, project officer with HCFA’s Office of Research and Demonstration. "One of the benefits of the EverCare program is getting the nurse practitioner’s skills and expertise in the nursing home and training the staff to provide more of these high-tech services," he adds.

Although instances requiring subacute care so far have been few, the program is working as planned. "This project is absolutely demonstrating that we can provide subacute care when the patient arrives back to the facility following surgery or for other subacute care. Because the patients usually arrive cognitively impaired, it’s critical to watch certain affects, such as skin breakdown, and that’s where the nurse practitioner involvement helps," adds Ryan.

Next, the nurse practitioner should serve as a clinical resource for nursing staff in the skilled nursing facility (SNF) to train them in providing services associated with subacute care, notes Ryan. "The RNs and LPNs like the notion of an added professional that’s available in the facility. The nurse practitioner becomes someone to bounce ideas off of, and physicians are sometimes hard to communicate with, whereas the nurse practitioner is more nursing-oriented," she adds.

EverCare’s nurse practitioners are available for staff inservice training on subacute care such as wound care techniques and IV medication administration. "[The nurse practitioners] can also provide patient and family education, coordinate discharge planning with the hospital, and relay medical information to the patient’s physician," adds Ryan. HCFA’s Miller agrees with the EverCare philosophy of extending the physician’s involvement into the SNF with the use of a nurse practitioner. "The patient’s physician all too often doesn’t see them as much in the nursing home, and having the nurse practitioner there to provide the high-tech care can hopefully eliminate some of the disorientation and complications associated with leaving the facility for surgery and then returning for subacute care," he says.

Evaluations to follow

HCFA officials currently are developing the specifications for evaluating EverCare’s effectiveness, says Miller. "We hope to have the evaluation ready by mid-1997. Things that will be included in the evaluation include utilization of services, patient satisfaction, and functional levels."

Miller says evaluation of the project will likely include existing measures for portions of the project. Results from the EverCare sites will be compared to a control group to determine if policy changes are needed, he adds.