Don't fall behind: Extend your services to 24 hours a day, 7 days a week

To succeed, all staff should reinforce functional goals

With the emphasis on cost cutting in today's health care environment, rehabilitation providers no longer have the luxury of saying rehab is something that happens Monday through Friday from 8 a.m. to 4:30 p.m. Instead, your rehab services should embrace more of a philosophy of care, something every member of your staff does to prepare a patient for discharge. Today's patients come to the rehab unit much sooner from the acute care hospital, and their lengths of stay are dramatically shorter than they were just a few years ago.

Let's face it, lengths of stay are not going to get any longer, and managed care and capitated contracts, as well as new Medicare reimbursement rules, mean reimbursement will decrease. For those reasons, you are challenged to do more for more acute patients in less time and for a lower cost. How will you do it? Your facility is going to have to provide rehab services 24 hours a day, seven days a week. "Since we have patients for shorter periods of time in rehab, and we are not going to be given more time, we need to look at how we can provide comprehensive rehab programs in a shorter time," says Chris MacDonell, national director for Medical Rehab ilitation at CARF...The Rehabilitation Accreditation Commission, with headquarters in Tucson, AZ.

New accreditation standards

CARF has new standards, which went into effect July 1, that require comprehensive integrated inpatient rehabilitation facilities to show they provide coordinated and integrated medical and rehabilitation services 24 hours a day. (For more information on the CARF requirements, see story, p. 135.)

Linda Peterson, MS, MBA, vice president of InteRehab at RehabLink/Marianjoy Rehabilita tion Hospitals and Clinics in Wheaton, IL, says, "When you think of it, rehabilitation isn't something that only the physical therapist does. Patients need the same consistent approach to activities of daily living throughout the day. Whether they need assistance in toileting at 11 a.m. on Tuesday or 11 p.m. on Saturday, they need the same approach."

At Marianjoy, the staff have been working for years to maximize every hour of the day because of pressures to cut costs and drive down the length of stay, Peterson says.

Providing rehabilitation 24 hours a day, seven days a week requires extensive communication among all staff so all will use the same cueing techniques, the same approach, the same equipment, and require patients to participate in a similar manner. (For a look at how Marianjoy has improved communication among all shifts, see story, p. 136.)

For instance, in the past, the night nursing staff did not always reinforce the bowel and bladder techniques used during the day shift. A sleepy or tired patient may have convinced the staff to help them more than the day staff did.

However, Peterson points out, when patients are discharged home, they may need to go to the bathroom during the night. It's up to the rehab staff to help them maintain the techniques so they'll be able to do it independently or with minimal assistance, she says.

No more bedpans

When patients go home, their family caregivers aren't going to want to provide a bedpan at 3 a.m., nor will it be practical for patients to take a wheelchair to the bathroom.

That's why Lourdes Regional Rehab Center in Camden, NJ, issues wheelchairs and bedpans only to patients for whom it is therapeutically necessary. This forces the staff to ambulate patients who need to practice their ambulation, even if it's in the middle of the night, says Tammy Feuer, MA, CCC, administrator of rehabilitation and post acute service. (For details, see story, p. 140.)

All staff must be cross-trained to therapeutically reinforce what the patients learn during formal training, says Connie Burgess, MS, RN, president of Connie Burgess and Associates, a Lakewood, CA, consulting firm specializing in rehab management issues.

Therapy techniques should be identical

Everyone who works with the patients should use the same therapy techniques so the patients aren't confused and their treatment is reinforced, whether it's the nurse, the therapeutic recreation specialist, the speech pathologist, or the physical therapist taking care of bladder function, Burgess explains.

Everyone on the team should know the plan of care and how to therapeutically reinforce it without having to call another person or letting it go until morning, she adds.

"Having cross-trained staff doesn't mean that the nurse become a physical therapist," she says. "The nurse is simply able to reinforce what the primary therapist has been working with."

In the past, nurses might have learned to transfer patients one way and occupational therapists might have learned another way. Speech pathologists might not have transferred patients at all. However, in today's rehab marketplace, everyone who works with the patients must learn how to transfer patients in the same way.

"We need to understand that there is no room for territorialism in health care," Burgess says. "Our customers are not interested in that. They want to know who can get the best outcome in the least amount of time for the lowest cost."

Facing the challenge

At the Rehabilitation Institute of Santa Barbara (CA) where almost all care is reimbursed on a case rate or per diem rate, it's a constant challenge to continue to provide quality care that meets individual patients' functional needs in a shorter length of time, says Melinda Staveley, MS, RN, vice president of clinical services.

In 1995, the facility took a transdisciplinary approach to therapy and required that all caregivers across the disciplines have some basic skills to meet the needs of patients. (For more information, see Hospital Rehab, now Rehab Continuum Report, June 1995, p. 78.) The Santa Barbara nursing staff uses the same strategies as the therapy staff to meet the functional goals of patients.

"We need to use every second of the day from a functional perspective and make sure that every interaction every staff member has with patients emphasizes their functionality," Staveley says.

For example, all the nursing staff receive mobility training, such as wheelchair transfers, dressing assistance, and ambulation, so they can assist the therapy staff if necessary or do some tasks at night or when no therapist is available. Other staff who do not provide direct patient care, such as the dietary and pharmacy staff, unit secretaries, and housekeepers, are trained to assist the therapy staff in tasks such as helping patients to the bathroom, in the event they are the only persons available.

[Editor's note, for more information, contact Nancy Beckley at (813) 654-4130; Connie Burgess can be reached at (562) 397-2050.]