Rehabilitation: Then and now

As an LTC professional since 1975, I have seen the pendulum swing, sway, get stuck in place, fall off and even be nonexistent at times. In 1980, I thought about having the staff care for the same residents each day. I had no idea that some 30 years later it would be called consistent assignment. One day, I went around the unit and made a list of all of the closet doors that did not shut, the faucets that would not shut off, the bed rails that were loose (yes, bed rails!), the curtains or blinds that would not shut and had the nerve to ask maintenance to check all of these things periodically so others would not notice that they needed to be fixed. All of us who have “been around” for awhile have similar stories.

“Back in the day,” everyone in the facility worked in his or her own tower. After all, the care plan was called a multidisciplinary plan of care. Each discipline put its notes in its own section of the chart, and set its own goals on the care plan. They never crossed paths or sat in an all-day meeting to set goals, or ask a resident when he or she liked to bathe. But, they lived in our facility. We made the rules and set the bath schedule. Too bad if the resident wanted to attend bingo on Tuesday morning. If that was his or her scheduled bath time, unless the hot water was shut off, that is when the bath was given. No ifs, ands or buts about it! We saw no need to provide PT, OT or ST. Why would a 75-year-old with a fractured hip ever want to walk again?

Restorative is an important part of therapy and, if done correctly, it should keep preventable decline from occurring.

In 1977, our first-ever physical therapist arrived in the building. He had a full-time hospital job and gave our facility a couple hours three times a week. We did not have his client schedule. He would come to the dining room and take the resident and his or her plate of food to the therapy room for treatment. This part-time physical therapist was paid a weekly flat fee; he would keep index cards in a small metal box with his notes on what he was doing for each of his patient/resident and their schedule. No one knew what his goals were and he never told any other staff…heck, why would staff members want to know what his goals were? Why would nursing ever want to help?

This “therapy room” was used for everything including whirlpool baths, a beauty salon and an in-service room. It was also where large deliveries were temporarily stored. Oh yes, it was also the place for all the extra wheelchair parts, walkers, the removable legs to the wheelchairs, heat lamps, rolling stools, and other items. The exercise bikes, stainless steel tubs, huge wooden parallel bars always were in the way, so often they were pushed against the wall or piled atop one another.

Spring forward 30 years…the silos are gone for the most part. Well-run facilities are interdisciplinary focused, with the team working as a well-oiled machine. Acute care is now discharging residents almost immediately after surgery with some of the first therapy sessions done at the LTC facility. The therapy department-yes-I said the department has speech therapy, physical and occupational therapists and a restorative team who work seven days a week.

Admissions occur 365 days per year. If we are going to send the resident back home, or be rehabbed enough to dance at his or her daughter’s wedding, we’d better rock and rock! Hospital readmissions must be avoided because soon our payments will be correlated to pay for performance, and bad performers will receive bad payments.

When our restorative team discharges a resident from active therapy, he or she cannot decline. If our team goal (when the resident is on the team) was to walk to all meals each day, and the resident reaches this goal, everyone is happy. Then a decline occurs because the regular CNA left and the new CNA is unaware of the goals and does not encourage the resident to walk because it is easier to push the resident to meals in a wheelchair.

A facility could receive a deficiency at survey for allowing a decline after discharge from therapy. The restorative team should continue to work with the residents after therapy is finished to ensure that a decline does not occur. Restorative is an important part of therapy and, if done correctly, it should keep preventable decline from occurring.

While many owners and administrators complain about this P4P [pay for performance], it might force everyone to become a team player. All staff-from CNAs to executive directors-will need to look carefully at the resident. The old saying, “You are not my resident,” will not fly. No particular department will own a problem; it will be the facility’s problem when the poor reimbursement check is received.

Many facilities “talk the talk,” using terms such as Eden Alternative, Pioneers, culture change, consistent assignment, and so on with buzzwords only. They jump from one new word to the next, never really making a difference to the care being administered to the residents, yet the terminology is all being used. Stop jumping from one new idea to the next. Make wherever you go a team approach.

If you want to make a difference in the therapy and care administered, consider:

• Finding the right tools to solve problems. Advancing Excellence (www.nhquality.org) has the tools, charts and graphs to help with most of the problems a facility encounters.

• Providing consistent assignment. Information on this topic is available from the Pioneer Network (www.pioneernetwork.net) or Advancing Excellence websites.

• Using Know-It-All Cards, available from AMDA-Dedicated to Long Term Care Medicine (www.amda.com, code NAD1); and NADONA (www.nadona.org), help nurses know what information they need to have on hand before calling a doctor about a resident’s problem. For example, if a resident has a cough, pull out the card before calling the physician. It will instruct the nurse to have certain information available, such as vital signs, weight, last lab values, chest sounds and pulse oximetry, before calling.

• Becoming certified by your association. Certification programs are available for all levels of staff.

• Keeping reference materials handy either online or in your office/home. “Favorite” those sites you visit regularly, and ones you don’t visit often. Let Google be your best friend!

• Hiring a nurse practitioner (GNP). Visit www.gapna.org for more information. GNPs have nursing facility practices managing complex care of frail older adults in collaboration with the interdisciplinary team.

• Encouraging continuing education. The National Student Nurses Association (www.nsna.org) along with NADONA have great scholarship programs. Many other scholarships available, just Google “scholarships + healthcare” and you will find many sites to choose from.

We have certainly come a long way from the ′70s silos and working independently of one another to the neighborhoods of today, working as teams while in the facility and electronically connected while away. We still have a ways to go, however, to ensure that all residents receive the quality of care they deserve. Recruiting team players, educating and certifying our staff in their areas of expertise and taking advantage of the latest technology will certainly be a win-win for all involved.

While many owners and administrators complain about this pay for performance, it might force everyone to become a team player.

Sherrie Dornberger, RN, CDONA, FACDONA, is President of the National Association Directors of Nursing Administration (NADONA). Long-Term Living 2011 August;60(8):22-23