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A Look at the Future
Home » News » A Look at the Future |
The basically healthy patient who comes to the nursing home to recover from a broken hip has gone the way of the pterodactyl. “Nowadays, that hip patient will probably have a number of other problems—pneumonia, congestive heart failure, COPD, diabetes, asthma, even obesity—and require both intensive therapy and extensive skilled nursing,” says Mark Richards, national director of clinical services for Aegis Therapies.
Historically, patient care has focused on crisis-intervention—providing care when a patient’s underlying impairments spike significant problems. Increasingly, however, the case is being made for a disease-management approach. “We’ve got to manage the condition that brings patients into the facility,” adds Richards.
CMS has gotten the message. In a February 2004 press release, CMS stated, “Disease management is a set of interventions designed to improve the health of these individuals by working more directly with them and their physicians on their treatment plans regarding diet, adherence to medicine schedules, and other self-management techniques.” Currently CMS is conducting demonstration projects on disease management at various sites around the country.
The benefits of moving toward disease management in the nursing home are significant. “Crisis intervention eats up time and resources—nurses and therapists field one problem only to move on to the next. It causes great frustration, and we know it’s not best for the resident,” says Dr. Barbara Paul, senior vice-president and chief medical officer for Beverly Enterprises, Inc., and former director of the CMS Quality Measurement and Health Assessment Group. “There is another way. We can learn how the large managed care companies and other forward-thinking organizations have shifted their focus from the disease model to the wellness model.”
While preserving wellness makes intuitive sense, reengineering patient care requires that facilities do a little out-of-the-box thinking. “The entire team needs a shift in mind-set from reactive to proactive,” says Dr. Paul. “We need to find ways to intervene early in order to tweak care, rather than initiating run-down-the-hall interventions.”
For example, Mrs. Smith enters the nursing home for therapy after knee surgery, but her diabetes is rampant. In therapy, she has good days and bad days, and nursing is constantly ministering to her flare-ups. Sound familiar? “It would be much more efficient financially and in terms of work flow simply to help Mrs. Smith control her diabetes day in and day out,” notes Dr. Paul. “If the focus were on wellness, her care team could think through and monitor her diet, exercise, what she and her family need to learn about managing her disease, and what her medication regimen is. For example, guidelines could alert staff, from therapists to CNAs, to symptoms of changes in blood sugar, with orders in place so medication could be adjusted earlier, rather than waiting until Mrs. Smith’s blood sugar hits 400.”
Disease management is a team effort. Nurses track Mrs. Smith’s physical condition. Therapists share their wellness goal of increased exercise for Mrs. Smith with her CNAs, who then make sure that Mrs. Smith walks in the unit for a half hour every day. Dietary teaches Mrs. Smith how to make the right choices in foods, rather than simply designing a menu for her. After discharge, Mrs. Smith returns for a wellness exercise program at the facility.
“The approach is to use the best of science to keep people at the highest level of functioning,” says Dr. Paul. “We must change our perception of these residents as facing a long inevitable decline to one that focuses on how we can help them live and thrive every day.”
In a way, Alzheimer’s care has taken a disease-management approach with specialized units that focus on comprehensive, interdisciplinary management of the disease through environment, programming, and medications.
That same kind of holistic thinking could be applied to the common diagnoses found in nursing home patients, such as heart failure, diabetes, asthma, depression, chronic pain, and weight management. Existing protocols drawn from physicians and managed care could be modified for nursing facilities. “Facilities don’t have to re-create that wheel,” says Dr. Paul. “For example, in the case of heart failure, physicians have well-known and well-studied paths that will keep the cardiac patient out of the hospital and functional, even with a weak heart.”
Disease management is one way nursing homes can move into the future successfully. “The complexity of these patients is not going to decrease, the funding is not going to increase particularly, and the regulatory oversight is not going to change in the near future,” says Dr. Paul. “We have to think of strategies for managing the care of these increasingly complex medical conditions. It makes sense to do and it has to happen.”
Very likely, CMS’s focus on disease management will result in some sort of reimbursement refinement for facilities that implement a disease-management program. When it does, will your facility be ready?
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