Rehab program slashes LOS for elderly patients
Community discharge rate exceeds the norm
Case management, preadmission discharge planning, and careful use of patients’ time have enabled the rehabilitation program at Columbia Northlake Medical Center in Tucker, GA, to cut the average length of stay for its elderly patients from 20 days to 13 days in just three years.The patient population of the 15-bed inpatient rehab unit primarily consists of older adults, with an average age of 70. The rehab unit has a community discharge rate of 89%, compared with a national rate of 85%, says Linda Maher Williams, MN, RN, CRRN, CCM, director of rehabilitation services at the suburban Atlanta hospital.
Since it opened in 1994, the unit has seen a consistent drop in length of stay from 20 days in 1995 to 17 days in 1996 and 13 days in the first quarter of 1997, Williams says.
About half of the patients have had strokes. The rest are orthopedic patients, mostly with joint replacements, or severely deconditioned patients who have been in the acute care hospital for long illnesses.
Williams often reminds her staff that in today’s rehab environment, "Every day counts, and you have to make the most efficient use of the time you spend with each patient. There is a lot of competition in this area. The only way we are going to be able to compete in the market is to be efficient and to provide excellent patient outcomes."
Because Columbia Northlake is small, the staff can offer individualized care, Williams says. This is particularly important to older patients who often don’t fit into a mold, she adds.
Because it is located within an acute care hospital, Columbia Northlake faces the challenge of treating patients who are medically stable but very sick. Some patients are still on telemetry when transferred to the rehab unit, Williams says.
Serving an elderly population gives the staff other challenges as well. "We have to deal with, and be aware of, a lot of chronic illnesses, in addition to the recent problem," she explains.
For instance, the team must push patients to improve functionally but must be careful not to fatigue them. If patients say they are tired, the staff must determine if they are tired from the therapy, or if their medical condition has changed suddenly, something that happens frequently with the elderly, Williams says.
When patients are referred to the rehab unit, clinical evaluator Carla Hamilton, RN, visits them in the acute care hospital and gathers medical and psychosocial information, then helps them and their families decide if the Columbia Northlake program is the right choice.
About half of the unit’s referrals come from Columbia Northlake. The rest are from outside the hospital.
"We needed a more efficient way to process referrals and to make it easier for the person making the referral. Rather than faxing pages of medical records, the clinical evaluator takes care of the details in person," Williams says.
Hamilton determines what the patients were able to do before the illness or injury, what kind of home environment and community they will be discharged to, and what the family’s caregiver resources are.
Then she begins working with the rehab team to develop a treatment plan based on the discharge disposition. For instance, a patient who has two flights of steps in his home would need to concentrate on stair climbing while in the acute rehab center, but a patient with one floor that is wheelchair accessible might have a different goal.
Within three days of admission, the entire treatment team, patients, and significant family members meet to discuss the goals and discharge plan.
A case manager pulls together the rehab plan, makes sure the goals are met, reinforces the discharge plan, and coordinates the team conference, family meetings, and family training sessions.
Constant communication among team members is another key to the successful program for the elderly, Williams says.
"We emphasize that everyone on the team knows all the facts about the patient," she explains. "We’ve all worked in places where the case manager and the nurse know that the patient has to go upstairs to take a shower, but the physical therapist doesn’t find out until discharge time."
At Columbia Northlake, the weekly team conference focuses on these barriers to discharge. Along with team and discipline goals, the team discusses what might keep the patient from being discharged and what can be done to avoid a longer length of stay.
If the patient’s goal is to be able to climb the stairs at home, that becomes a goal the entire team focuses on. Elderly patients often need to build endurance to gain the energy needed to walk up stairs. If this is the case, they walk to their meals in addition to working with the physical and occupational therapists on endurance. If they can’t walk on their own, patients may use a walker or self-propelled wheelchair.
The hospital has installed information boards in patients’ rooms to remind the staff to reinforce the goals and to make sure the patients understand what they are supposed to do.
It’s up to the unit nurse to assess whether the patient can walk to meals that day.
"With elderly patients, there can be daily medical changes that can change their rehab goals," Williams says. "Nurses who work with the elderly have to be skilled in assessing patients’ conditions."
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