Skilled nursing facilities (SNFs) nationwide are grappling with higher acuity rates and the challenges that come from caring for high-risk populations in a reimbursement-driven environment that demands a reduction in unnecessary hospitalizations. But few SNFs can claim a higher acuity resident population than Silvercrest Center for Nursing and Rehabilitation, Briarwood, N.Y., Long-Term Living’s 2015 OPTIMA Award winner.
At this 320-bed nursing home, deep in the middle of Queens, an extraordinary 43 percent of the resident population is ventilator-dependent or has been tracheostomized. Feeding tubes and breathing tube maintenance are the norm here, rather than the exception.
Yet, the site has achieved a 34 percent reduction in its 30-day hospital readmissions in the past 18 months, including a whopping 54 percent reduction in 30-day readmissions among the residents in the ventilator unit.
Silvercrest’s model program for cross-discipline care uses customized documentation tools, unique staff training and innovative leadership to provide early clinical intervention and reduce hospitals transfers, despite its resident acuity. In other words, if a hospitalization reduction program can succeed here, it can succeed anywhere.
The hospitalization reduction program
Silvercrest is part of the New York Reducing Avoidable Hospitalization (NY-RAH) demonstration project group, a 20-site collaboration between New York State and the Centers for Medicare & Medicaid Services (CMS). But Silvercrest’s own initiatives within the program have resulted in a goldmine of quality care data and advanced protocols for high-acuity populations. “We started with reducing hospitalizations, but as we did our resident transfer reviews, we saw what we could do to improve our clinical practices and documentation,” explains Denise Lawson Munroe, RN, director of performance improvement and risk management.
Silvercrest’s implementation of early-assessment clinical tools, deeply customized electronic charting templates and specialized staff training have made it the top performer among the state’s hospitalization reduction group, despite the site’s unusual acuity rates. “Silvercrest is NY-RAH’s poster child now,” says Marva Skeete-Phillip, RN, RNCC, the CMS liaison for the NY-RAH program.
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The Rapid Response Tool (RRT), used by many hospitals, has been finessed to a fine process point at Silvercrest. Accurate assessment and early intervention can keep the “little emergencies” from becoming life-threatening ones that require a hospital transfer. The RRT works like a hospital emergency code, calling in all available hands when something is going wrong with a resident. “It’s not a tool you see used much in long-term care,” Lawson Munroe says. “It’s a quick catch for a resident who seems to be declining quickly. It’s about doing a thorough assessment of a resident to determine whether a hospital transfer is needed, or what can be done right now to prevent a transfer.” At many SNFs, a hospital transport can occur simply because the staff lacks the training or equipment to deal with emergencies in house, she adds.
Most SNFs use shift reports to make sure each nursing shift is aware of current resident statuses. But Silvercrest’s morning care team meetings include not only the medical director, director of nursing and the director of quality improvement initiatives, but also the directors of social services, speech/language pathology, rehabilitation, therapeutic recreation and admissions, as well as nurse managers and coordinators of clinical nutrition and MDS.
The daily discussion includes admissions, discharges, hospital transfers and any resident changes of condition or therapy in the past 24 hours. In the conference room, two flat-panel wall screens display the electronic chart of each resident being discussed, providing easy access to real-time nurse charting notes, the electronic medical record, medication administration lists and dietary/feeding notes.
The customized charting system flags all SBAR (Situation, Background, Assessment and Recommendation) notes and changes in condition as high priority, using a red flag icon. No matter which person originally entered the notes, everyone can see the same information at the same time during the morning meeting, so future therapy adjustments can be discussed as a team.
At Silvercrest, most of the residents have extremely limited mobility, if any at all. Among this unusual population, many nurses and respiratory therapists (RTs) are trained in advanced cardiac life support (ACLS). All staffers—from nurses to housekeeping and maintenance personnel—are trained to use the “Stop and Watch” tool to recognize changes in resident habits and vital signs, and in the protocols of what to do when something is amiss.
Yet, the CMS reimbursement rates don’t always adjust for such high acuity levels, Lawson Munroe points out. “We’re basically like a long-term acute-care hospital (LTACH), but since New York State doesn’t have LTACHs, we’re not being reimbursed for that level of care.”