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Passing the Baton
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Clinically managing the medically complex patient is somewhat like running a relay race: Nursing and therapy must match stride and coordinate passing the baton—the understanding of the patient’s disease, status, and goals—as each takes over the next lap of care.
Take the case of Mr. Jones. Because of his COPD and diabetes, Mr. Jones’s days are difficult. Nursing tries to get him ready for therapy, but he becomes short-winded just sitting on the edge of his bed. In the old days, the two worlds of nursing and therapy might not have intersected in Mr. Jones’s care. Therapy would have found him too sick for treatment, and nursing would have taken charge of his medical needs. But with more and more patients arriving on facility doorsteps with multiple underlying impairments, that old model of isolated care no longer works. Nursing and therapy are in the race together and each needs to know how to help the other in addressing all of Mr. Jones’s needs.
“Our facility is trying to find a balance between therapy and nursing, so patients can achieve therapy goals but we can also deal with their medical needs,” says Vicky Wieder, director of nursing at Beverly Healthcare Titusville in Titusville, Pennsylvania. “In the past, nursing and therapy each had their own territory and that communication didn’t happen. Now we talk about what nursing issues may be hindering a patient in therapy and how therapy can help nursing. We had to realize that we both have the same goal—for this person to get better.”
Dealing with patients who have comorbidities in addition to their therapy needs has taken nursing and therapy beyond the interdisciplinary model, in which they consult with each other, to the transdisciplinary model, in which they not only consult, but carry over each other’s goals. In other words, as the patient goes through his or her day, therapy and nursing pass the baton back and forth to monitor physical and functional progress and relapses, and to coordinate timing and delivery of care.
“Nursing can work with therapy to successfully structure the resident’s day,” says Barb Christensen, clinical director for Aegis Therapies. “Nursing needs to tell therapy what’s happening with the patient in medical terms; it’s the therapist’s responsibility to share with nursing such information as proper breathing techniques and the energy requirements to perform simple activities. CNAs can then incorporate that into the daily routine.”
The transdisciplinary model augments the standard care planning meetings and even stand-ups with a more informal form of communication—simple conversation. “I have a close relationship with the LPNs on the unit, and we talk informally about the patient all the time,” says Mary Brown, a PT at Trussville Healthcare, Trussville, Alabama. “Nursing and therapy have to agree on such issues as how long the patient should sit up, why she is so tired, and how medication is affecting her performance.”
Historically, nursing and therapy have not always communicated effectively, so such a close relationship may be a new paradigm. “If you haven’t had a history of nursing and therapy talking to each other, it takes a real concentrated effort to make sure you touch base several times a day,” says Larry Pupp, executive director at La Crescent Healthcare, La Crescent, Minnesota. “You can set up a schedule and talk about it at a stand-up, but after lunch the patient may have a bad afternoon; he may not be able to breathe well, so things can shift from moment to moment. Every time there is a change in the individual, therapy needs to check with nursing and nursing needs to communicate with therapy.” If this seems burdensome, Pupp has good news: “It gets to the point where it’s second nature.”
THERAPY'S NEW MISSION
In addition to expanded communication needs, the basic delivery of therapy has new requirements for the medically complex patient. “These patients lead us in a different direction from the typical orthopedic or stroke patient,” says P.J. Rhoades, regional director of clinical services for Aegis Therapies. ”Their underlying impairments guide us into different areas of the evaluation, such as monitoring patients’ vitals, measuring their tolerance for therapy, and understanding their psychosocial profile.”
Here are some of the ways a good therapy department can contribute to the care of the medically complex patient:
1. Education—Everyone in the therapy department, not just one or two staff members, should understand and be trained in managing residents with the more common disease processes, such as COPD, pneumonia, heart disease, renal failure, diabetes, etc. Ideally, in addition to internal training, the therapy company will encourage therapists to pursue continuing education. “In our region we conduct regular continuing education courses and clinical leaders do follow-up calls,” says Angela Edney, clinical director of operations for Aegis Therapies. “Master clinicians are available for consultation, and therapists can request information in a ‘think tank’ conference call with several clinical leaders who have special training and expertise.”
The therapy department can also provide formal or informal in-service education for nursing, covering such topics as how therapy can help nurses monitor the patient’s physical status and how specific techniques can be helpful. “Our rehab coordinator will drag the whole staff in for five minutes to show us how to do something—a transfer, how to put a belt on, or what certain support boots are for,” says Judy Bickel, LPN at the subacute unit of Colonial Manor in Glendale, Wisconsin. “She invites nurses to ask her whenever they have a problem. The CNAs often ask her for help, too.”
Education for the patient and family is vital. For patients with severe diseases, anxiety often impairs their ability to function as much as does physical frailty. For example, patients with respiratory problems are frightened when they become short of breath. Therapists trained in a disease process can help relax patients by explaining exactly what’s happening, what therapy is doing, and why.
2. Expanding assessment tools and treatment—For therapists, clinical assessment of the medically complex patient goes deeper than the customary focus on function. “This type of patient cannot always express how he feels,” says Jodi Czernejewski, regional director of clinical services for Aegis Therapies. “You have to be able to look at other signs and symptoms—sweating, pupil dilation, heart rate, blood pressure, oxygen saturation.” All therapy disciplines are involved in measuring respiratory function, cardiovascular function, work capacity versus endurance, pharmacy needs and complications, and functional activity assessments. Treatment often includes using vital signs as the road map to appropriate care.
“We take vitals because it’s important to know what happens when the patient is engaged in activity,” says Cheryl Robillard, PT, clinical specialist for Aegis Therapies. “We can compare those levels to the vitals nursing takes when the patient is at rest. I’ve found that nursing is appreciative that we can help them monitor patients because our information helps them better treat the patient.”
Because respiration is so often an issue, the therapist must monitor breathing and teach breathing strategies. “I don’t think therapy ever taught people to breathe; we just stood back and waited for the patient to catch her breath,” says Brad Miller, district manager for Aegis Therapies. “Now we are not only looking at how the muscles work, but at how the organs work, how the body is working together.”
3. Changing goals and documentation—Because severely ill patients don’t show progress quickly, therapy documentation has to be geared to small changes and the underlying impairments that are actually causing the functional deficit instead of focusing on the big functional areas of ADLs, mobility, or swallowing. “It’s a whole different way of looking at documentation,” says Rhoades.
“We have to gear documentation down to smaller goals. For example, we would note how the patient can now tolerate 30 seconds of standing versus the 5 seconds when she went on caseload. Then we have to communicate with nursing about the types of things we’re documenting so their documentation can support that.”
Remember our Mr. Jones sitting on the side of his bed and short of breath and the therapist, untrained in medically complex care, who has thrown up her hands because Mr. Jones is too sick for a therapy session? That scenario appalls Miller. “If I were an administrator or nurse and a therapist told me the person isn’t well enough for therapy, I would see red flags, because that therapist is really overlooking what can be done for the patient,” he says. “Sometimes the patient needs to take small steps toward a larger goal.”
For example, working with nursing, the therapist’s goal might be to build Mr. Jones’s activity power so he can sit on the edge of the bed for five minutes. The next goal might be to look at his sitting balance. And then move on to his standing balance. “We’re using a different yardstick with the medically complex patient,” says Brown. “Before we were trained to work with the medically complex patient, we might have said we couldn’t work with the patient. Now we’re grading the activity, progressing them in slower steps, and monitoring them much more closely.”
4. Scheduling—Coordinating the scheduling of therapy during the patient’s day is a huge component of caring for the medically complex patient. “We need to coordinate the times we treat those patients because they are so debilitated,” says Robillard. She cites the example of a patient with lung problems who has pneumonia. If the nurse just finished a breathing treatment, the patient will be too tired to tolerate therapy. Or if a patient is due for pain medication, a therapy session will probably not be productive. Even taking a shower can use up so much energy for a severely ill patient that he or she will not be able to tolerate therapy until after a rest period.
Because medically compromised patients can rarely tolerate the hour or hour-and-a half therapy sessions common with orthopedic patients, the entire structure of therapy has to be adapted. “These patients can sometimes only tolerate 15 minutes of therapy, so we’re continually going back to the patient’s room or seeing them three or four times a day,” says Rhoades. “We constantly update the nurses to tell them how the patient has tolerated the therapy.”
A WORD ABOUT WELLNESS
Because people are living longer, it makes intuitive sense that nursing homes will continue to see a rise in medically complex patients. Preventive healthcare and wellness are strong components in managing these patients’ underlying diseases. “I don’t know if a lot of nurses and therapists know how important wellness is in terms of preventing or delaying those crisis periods of these patients,” says Rhoades. “It’s important to have a wellness or prevention program in place to continue with the patient’s exercises or mobility goals.”
The bottom line is that therapy will ultimately discharge the patient, but nursing will continue to care for that patient. It becomes nursing’s task to follow through with therapy recommendations on a daily basis and to let therapy know when those recommendations stop working so the maintenance program can be altered.
“As we move forward with the aging population, it’s incumbent upon all of us to incorporate concepts of wellness into our activities programs and into the way we interact with our patients,” says Aegis’s Christensen. “It starts with a philosophical change. We have to stop seeing the nursing home as a place of treatment and medical intervention and see it as a place where we teach people how to have the highest quality of life they can for as long as they remain in the facility.”
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