Enhancing clinical services without going subacute

Nursing Homes, June, 1996 by Richard Friswell

if you can't, or don't want to, step up to subacute, there is still way a to stay competitive

For many nursing homes doing business in today's marketplace, merely providing quality long-term care is no longer sufficient to establish and maintain a reputation for excellence. While the combination of solid clinical services for the resident, good family relations and attractive amenities go a long way toward anchoring a facility in the community, many nursing homes have discovered that they are, nevertheless, losing market share and census to competitors. In this era of consolidations, large chain buy-outs and publicly traded nursing home corporation stock, competition in local markets is often driven by multimillion dollar players with teams of marketers, sophisticated demographic analyses and expensive promotional materials.

For the small to mid-sized operator who begins to see shifts in facility admissions patterns, often after years of stability and success, the trend can be alarming. At best, it may signal a need to promote the home and its services more aggressively. At worst, a radical overhaul in the physical plant and clinical programming may be necessary.

It is often at this juncture, or in anticipation of this scenario, that the nursing home operator turns to the newly defined "subacute" or "managed care" product areas for potential revenue enhancement, improved market share, competitive advantage, etc. The collective groundswell of interest in positioning a nursing home as a subacute provider is often undertaken as a knee-jerk response to the impulse to "keep up with the industry," and not so much because the facility wants to, or is ready to, offer subacute services.

Many attempts have recently been made to define the range of services encompassed by the term "subacute." These complex definitions have all been useful in helping the long-term care industry attempt to delineate an opportunity. By redefining the health care continuum, the nursing home can treat patients in lower cost settings and in different ways than the acute care facility. The changing definition of what constitutes a "hospital inpatient" and the search for savings on the part of managed care companies has clearly catalyzed this trend.

In light of these shifts, this article will deal with the questions: How can your small to mid-sized facility position itself with enhanced clinical services to keep your competitive edge in the marketplace without major capital expenditures? And how, at the same time, can you maintain a reputation for excellence? Finding the answers requires that you take an honest look at your current capabilities and how you would like to be positioned one to two years from now.

If your facility has historically occupied a position in the market as a quality provider of long-term care and you are challenged by the trend toward subacute care, consider developing a "team-based" program as a step toward a more sophisticated level of clinical activity. This team-based model has many of the enhancements of an expanded rehabilitation and nursing program, but without the operational demands and financial complexities that the managed care and subacute areas generate.

Recognize, at the very least, that if you ever wish to undertake the transition from long-term care to subacute (as depicted in [ILLUSTRATION FOR FIGURE 1 OMITTED!), it will be much more difficult, if not impossible, to do so without passing through the intervening steps described in this article. So, at the very least, the enhancements of a team-based model (table 2) are necessary first steps in the direction you wish to go.

Making the move from a long-term care nursing home to a team-oriented facility can be a dramatic and effective one, because it moves the locus of control from the nursing department alone to the interdisciplinary team. The gain is often defined in terms of empowering the other members of the clinical staff to play a more active role in patient care decision-making.

The move from long-term care to an enhanced model of care can be accomplished with only minor changes in the [TABULAR DATA FOR TABLE 2 OMITTED! structure or presentation of your clinical programs. Because you will be depending more on your therapy team and they will be more active, consider expanding their space and increasing the equipment and supplies needed to treat a broader range of patients. Remember that Medicare will support your square footage allocations and therapy supply cost, and it will be important to have those resources in place when you tour families and discharge planners through your new program.

Other steps that may be required in order to increase the effectiveness of the team-based program are:

a. expand the hours and service contract of your therapists to include hours in the building doing staff training, restorative program development, screenings and patient observation, and topical inservicing in their selected disciplines.

b. designate a time each week for Medicare patient review as a separate event from patient care planning or MDS review.