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Alliance (OH) Community Hospital’s Center for Rehabilitation decided not to wait for the prospective payment system (PPS) before making changes that would benefit patients, payers, and clinical care quality.
Three years ago the hospital’s chief executive officer challenged the rehab director to eliminate inefficiencies and therapist shortfalls by moving from a compartmentalized approach to an integrated approach, recalls Cyndia Schreiner, BS, CRRN, LNHA, director of rehab services and administrator of long-term care for the hospital.
"I was given responsibility for the long-term care facility and all of the therapies across the continuum, and I was told to make it work," Schreiner says. "I had no long-term experience at all because I’m a dyed-in-the-wool rehab nurse, so it was swim or drown."
Schreiner formed a total quality service team that identified the facility’s most urgent concerns and its greatest assets. "We had a body of people committed to good patient care," Schreiner says. "That was one common thread that ran in every one of us, and we were able to weave those threads together and come up with a product called the continuum of care."
The result has been greater patient satisfaction, and the facility is building up physician referrals. "We have a patient satisfaction tool, and patients are singing our praises," Schreiner says.
The change also helped the hospital to boost its outpatient rehab volumes. Physicians who might have sent patients to other outpatient facilities could see that Alliance offered patients consistent therapy care, often with the same therapists following a patient from acute through outpatient treatment, and this resulted in more referrals.
Here are the steps the facility took:
1. Identify problems.
"What we identified first was that we had a shortage of therapists," Schreiner says. "We saw that at any given point in time the acute care hospital or outpatient or long-term care facility could have either feast or famine."
When the departments had a shortage of rehab therapists they would use contract services to fill the gap. This not only cost money unnecessarily because there likely were qualified therapists elsewhere in the hospital who had open slots that week, but it also led to less consistent patient care. Since the change, staff fill in the gaps, saving the facility money on contract services.
"We wanted to give good patient care and that’s why we got rid of all territorial barriers," Schreiner says. "If you’re an outpatient therapist and your mom is on the rehab unit or in the nursing home, don’t you want her to have access to the best services, and if you can be the one to provide those services because your workload is down, don’t you think that would be a great thing to do?"
2. Cross-train staff.
Alliance Community Hospital had nurses do rotations through the various therapies, including physical therapy, occupational therapy, speech, and recreational therapy. "The nursing staff followed-through with the same approaches that therapists were doing," Schreiner says. "This way we had a 24/7 approach so that what patients learned in therapy was carried on with nurses working at 3 a.m."
Therapists were cross-trained and rotated to spend time in the various settings. For example, an inpatient rehab therapist would spend a day or longer in an outpatient rehab setting and then in the nursing home. This continued with the therapists who were primarily assigned to the other settings until every therapist knew how to work in any of the sites along the care continuum. The only exception was home health, where it was more cost-efficient to keep separate home health therapists.
"After everyone was cross-trained, any therapist could fill in at almost any point in our continuum," Schreiner says.
3. Move closer to a 24/7 philosophy.
One of the big changes rehab facilities will experience under PPS involves the work-day philosophy. Therapists have grown accustomed to having evenings and weekends off. But this 8 a.m. to 5 p.m. schedule does not always work best for patients or for achieving the best quality of care.
Schreiner says that inpatient rehab facilities may have to change to a more flexible therapy schedule. Some long-term care facilities made that sort of change when their field was hit by PPS. "When PPS came to long-term care, we needed to identify a mechanism where we could give the patient the biggest bang for the buck," Schreiner says. "At that time in our community for a therapist to even consider working on a Saturday was rare."
Now the hospital has Saturday therapy coverage in the acute hospital, inpatient rehab, subacute, long-term care, and outpatient rehab settings. Rehab therapists also provide some weekend coverage to a separately owned facility through a contract. "We have therapists on call on holidays, and everyone is striving for the same goal of quality outcomes," Schreiner adds.
4. Achieve staff buy-in for changes.
"Some therapists were very resistant to the changes," Schreiner says. "But once they got into it, it was a wonderful learning opportunity for them."
At rehab service meetings where all disciplines gather, Schreiner explained to the staff how PPS is changing the way rehab is done and the way its documented. Therapists were told that nurses, therapists, and other members of the rehab team needed to be speaking the same language and doing things the same way. All of these changes would result in better patient satisfaction, a goal that has since proved true.
"The greatest thing that helped us with buy-in was the fact that we wanted to see our outpatient referrals grow," Schreiner says. "So we identified that if we could streamline the inpatient length of stay by providing services on Saturdays, then we could get these patients out sooner and they’ll go to outpatient care."
Also, inpatient therapists now communicate more closely and effectively with their counterparts in the outpatient setting, so patients can be assured of more consistent care. Occasionally an inpatient therapist may fill in for an outpatient therapist and follow the same patient across the care continuum.
While all areas now have Saturday coverage, soon, because of PPS, some Sunday therapy probably will be scheduled as well, Schreiner says. "It would be so much more seamless and easier for patients," Schreiner says. "And we offer scheduled time off during the week for those working on weekends."
Schreiner sold therapists on the idea that it’s not so bad to have a day off during the week every now and then. "With the volume of therapists we have they don’t have to rotate onto a weekend except for once every five or six weeks," Schreiner says.
Therapists also have grown accustomed to working on holidays, although that also required a buy-in. "The key was to be empathetic and sensitive and listen to what they had to say," Schreiner explains. "I kept on reminding them, Remember, we all said we want to give the best patient care we can.’"
The final strategy to achieving staff buy-in was to give therapists flexibility. They could change days and hours with other therapists to accommodate child care, weekend family activities, and other requirements.