Rehab center develops unique caregiving model
When administrators at Bryn Mawr Rehab in Malvern, PA, set out to create a new caregiving model, they found no other to benchmark against. Now that they have one in place, other facilities are calling them to learn more about their innovative redesign that integrates nursing and therapy into work teams reporting to the same supervisor. Traditional models and most redesigned models maintain separate reporting structures for the distinct disciplines.
Here, Daniel J. Keating, PhD, administrative director for the neurocognitive division shares Bryn Mawr’s model with the readers of Healthcare Benchmarks.
To reconfigure the staffing structure, Bryn Mawr’s redesign team eliminated a tier of management: the directors of each of the therapy disciplines, Keating says. Now the clinicians and support staff work in self-directed teams and report to a coordinator who may be either a nurse or therapist. Job roles also have changed. By cross-training employees to perform a variety of skills, some positions have been combined.
Care teams huddle up
The care teams are assigned to specific patients, 10 to 13, depending on the rehabilitation program. Every morning they meet to review their cases. "The huddle," as Keating calls it, provides every team member with a thorough understanding of the patients’ progress and needs. Bryn Mawr leaders adopted the idea from the Shepherd Center in Atlanta, which they visited during the benchmarking phase of the restructuring process.
Combining job roles and creating self-directed work teams streamlined communication and pushed decision making closer to the staff. The redesign has cut the number of staff interacting with a patient by 33.4%, a goal of restructuring, Keating says.
Bryn Mawr has 10 teams in six programs under two divisions. The neurocognitive division includes brain injury and stroke programs, and the orthomedical division includes musculoskeletal, medical rehab, amputee, and spinal programs. (See staffing structure charts, p. 28.)
Administrative directors provide vision
The redefined roles under the new model include:
• Administrative directors.
Head the two divisions. These two positions are entirely administrative. They provide the vision and leadership for the division and direct marketing plans and new product development.
• Program managers.
Serve under the administrative director. Slated for RNs or therapists with management backgrounds, these four positions also are entirely administrative. The managers create the budget, develop policies and procedures, improve processes, and evaluate the program. Of the two programs in each division, one is slated for a manager with a nursing background, the other a manager with a therapy background to preserve access to resources for discipline-specific questions, such as licensing, skills, or procedures.
"We didn’t want to lose our expertise," explains Keating. "With this, at least one knows the nursing ropes and one knows the therapy ropes."
Three of the four program managers oversee two teams, while the program manager in the orthomedical division oversees four: two medical rehab and two musculoskeletal.
• Team coordinators.
These positions are half administrative and half clinical. Candidates can be either nurses or therapists. The team coordinators implement the patient’s care plan, supervise and evaluate the team members, schedule staff, coordinate communication among staff members, and assist with patient care.
"The team comes up with the patient’s program, and the team coordinator makes sure it is implemented. They are responsible for the follow-through," Keating says. Under the old system, department heads’ duties were generally 80% administrative and 20% clinical.
Under the team coordinators are the clinicians, including nurses, therapists, and their assistants. These newly created assistant roles include:
• Rehab techs.
This position combines the roles of therapy assistants, nursing assistants, patient transportation workers, phlebotomists, and EKG techs. The rehab techs assist the therapists and nurses, and some are trained to draw blood and give EKGs. They assist one or two teams within a particular program, such as musculoskeletal, medical rehab, or brain injury. They do not cross over into other programs unless a staffing shortage or variability arises, Keating says.
Administrators are reevaluating the tech position. He says the initial plan was to train all rehab techs in phlebotomy and EKG, but they decided the training time and money would be a waste. "The demand isn’t as high for [EKGs and phlebotomy] as in an acute hospital, so if we trained all of them, there wouldn’t be enough blood draws or enough EKGs to keep them proficient," Keating explains.
Instead, the administration is considering training a select group in phlebotomy and EKG. Also, Keating said the administration is reevaluating the staff mix and may boost the number of techs because they are being taxed under the current staffing ratio.
• Patient support attendant.
This position, called a PSA, combines the roles of a variety of traditional positions, including nurses’ assistants, dietary staff, and patient transportation staff. The PSA has been cross-trained to clean patient rooms, pass out meal trays, escort patients to needed services, and answer a patient’s call bell. The creation of a PSA eliminated some housekeeping positions, but the department is still needed to clean public areas, such as the lobby and hallways.
Two other key positions also are on the team:
• Physician.
The physician leads the team, directing care. "We included this person in the team structure because we wanted people to still know the physician provides the medical leadership," Keating says.
• Case manager.
The case manager oversees utilization of both internal and external resources. The person is a liaison and resource between the team coordinator, the patient and the family, and the insurance company. "The family can go to the case manager with any questions," he says. "And, if the family has a concern or complaint, the case manager will bring it to the attention of the team coordinator."
The teams are fully staffed during the day but taper during the evening and night shifts when needs decrease. For example, a team serving 12 stroke patients during the day would include 14 nurses, therapists, and support personnel. In the evening it would consist of one RN, one LPN, a rehab tech, and a PSA, whose time would be split with another team. At night, the team is composed of an RN or an LPN and a rehab tech.
[For more information, contact Daniel J. Keating, PhD, administrative director, Bryn Mawr Rehab, 414 Paoli Pike, Malvern, PA, 19355. Telephone: (610) 251-5416.]
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