MDS Alert

3 key strategies target common areas of vulnerability.

SNFs with a revolving door of rehab patients going back to the hospital may find its referral sources knocking elsewhere. Not only that, but the federal government has rehospitalization rates blazing on its radar screen -- and a major portion of patients in SNFs are on rehab.

The good news: Coordination between nursing and therapy can target common reasons that patients fall through the safety net and land in the ED or hospital. Consider these three steps:

1. Give therapists' training a check-up. Therapy staff must be able to spot early signs of exacerbations that could eventually result in a return to hospital, stresses Mark Besch, PT, VP of clinical services for Aegis Therapies, which uses strategies to prevent rehospitalization in its chain of SNFs, Golden LivingCenters. "These include cardiac impairments such as congestive heart failure, pulmonary conditions such as COPD or emphysema, and more."

Problem: "In SNFs, you don't routinely see therapists monitoring things like pulse oximetry, blood pressure, and before and after exercise physiological signs, etc.," observes Martha Schram, PT, president of Aegis Therapies. "Yet therapists should be held accountable to that level of training and should be partnering with the facility to monitor these fragile patients." Keep in mind, however, that it's not an overnight training process. Golden LivingCenters doesn't try to cram it all into a new therapist's orientation. "But at the appropriate period in their employment, we do have therapists undergo a rather extensive training that includes understanding pulse oximetry and monitoring blood pressure, etc., to the depths that we think is necessary," Besch says. "We also  have the training available in an elearning format where therapists can review it on-demand and repeat it as often as needed."

Good idea: Golden Living-Centers also created a peer-to-peer pool of experts whom therapists can contact for clinical support, Schram says. "And our therapists really value that," she adds.

Therapists should report to nursing any changes in their patients' performance. That could be more swelling in a limb, more shortness of breath than the prior day, etc., Besch says. "The patients can't tolerate much decline or exacerbation until it really becomes a medical issue, and if we don't recognize and respond, we're in a situation where there's no choice but to return the patient to the hospital."

Rule of thumb: At the very minimum, therapy should be communicating with other staff on a weekly basis, Besch says. "But keep in mind that depending on the profile of your facility's admissions, you may need daily communication."

Tip: Your SNF's entire staff needs to realize it runs a 24-7 program and know how to handle many smaller issues internally. "Don't just call the doctor for any little sign of decline," Besch says."The on-call doctor doesn't know the patient, and he's probably going to say, 'it's hard for me to tell over the phone; why don't you just send him to the hospital?' And then you have a readmission."

stats. Every SNF should analyze its hospital readmissions experience in collaboration with therapy, Schram insists. "Then the facility can design a risk-management and intervention strategy that includes not just nursing and rehab, but far more departments than that in the facility."

Example: Besch recently visited one of the Golden LivingCenters that had analyzed when their highest return to hospital rate was occurring. "They found out that in fact, it wasn't weekends, to our surprise; their highest return to hospitals was Wednesdays between 10 a.m. and noon," he recalls. "That's important to know. So the next question is why would that be? And that's where they are in the process -- figuring that out."

Editor's note: The original version of this article appeared in Eli's Rehab Report, Vol. 16, No. 9. For subscription information, call 1-800-508-2582.