Trend Shows Continued Growth in Short Stays

Abstract

DALLAS — The face of nursing facilities continues to take on new characteristics. The aging of the baby boomers, changes in regulations and reimbursement, and other factors are changing the face of nursing facilities, Dr. Keith Krein, CMD, said at the annual symposium of the American Medical Directors Association. “Nursing facilities have moved from custodial care to health care services in the last 15 years,” said Dr. Krein, senior vice president and chief medical officer of the health services division at Kindred Healthcare in Louisville, Ky. “A higher acuity of patients has begun to come and continues to be coming our way.” “We are seeing two distinct long-term care populations evolve—long stay and short stay,” he said. Although the general characteristics of patients transferred to LTC remain much the same, the increase in the number and rate of these transfers—combined with the decrease in hospital lengths of stay—indicate an expanding substitution of subacute care in LTC facilities for hospital inpatient care in the '90s. Dr. Krein used statistics from his own facilities to underline the trend. “The number of short-stay patients is becoming larger and larger in our world,” he said. With these patients come changing demographics. For example, “about 30% of our patient population is below age 74. This is primarily due to the influx of short-stay patients.” The growth of the number of short-stay patients presents some challenges to the facilities and their physician leaders. As Dr. Krein explained, there is interplay of psychosocial and medical issues in short-stay patients, when compared with long-stay patients. According to Dr. Krein, issues for the short-stay patients include: ▸ The nursing staff and physician may be unfamiliar with the patient's baseline health status. ▸ The patient and family may not be familiar with the nursing facility environment and caregivers. ▸ The patient and family may have unrealistic family expectations regarding the new environment. ▸ The patient may experience deterioration of health status that cannot be explained or that the family is not ready to accept. ▸ There may be instability in the subset of newly admitted patients. ▸ There may be a need for hospital-based diagnostic interventions and consultations to sort it all out. Conversely, issues for the long-stay patients are: ▸ There is a previously established baseline health status and baseline psychosocial status. ▸ Staff has a general knowledge of the patient's chronic conditions and prior issues. ▸ There is an appreciation of family expectations. ▸ The patient and family are familiar with nursing facility environment and caregivers. ▸ The family generally accepts that all that can be done has already been done during previous hospitalizations, treatments, etc. Facility leaders and their staff must adjust to the fact that their long- and short-stay patients have different goals and needs. For example, Dr. Krein said, “short-stay patients don't care about a nice dining hall and extensive recreational program. They are focused on getting their rehab, taking their meds, and getting well so that they can leave the facility.” Dr. Krein also suggested that facilities can expect to see more hospitalizations with short-stay vs. long-stay patients. “With the long-stay patients, there are greater options and a wider array of options for care and assessments as alternatives to hospitalizations” that these patients and their families will find acceptable. With short-stay individuals, there are more likely to be “occasions where patients are transferred to the hospital irrespective of the nursing facility staff's competence.” Facilities will have to be more flexible to balance the needs and goals of short- and long-stay patients. This will allow facilities to improve care delivery to accommodate increasing patient acuity and rising transfer rates for the Medicare and managed care populations. Dr. Krein said this also presents “more opportunities for medical director supervision and involvement, improved attending physician relations, and the use of clinical protocols.”