This article is sponsored by Aegis Therapies. This article is based on a Skilled Nursing News virtual presentation with Patricia Wike, National Director of Continuing Care, Dawn Greaves, Chief Clinical and Innovation Officer, and Brian Boekhout, Vice President of Wellness Services, at Aegis Therapies in October 2022. The article below has been edited for length and clarity.
Patricia Wike: This presentation will focus on moving beyond therapy-driven case management and reimbursement into a fully collaborative and integrated model of care. SNF providers working under PPS can likely remember the therapy-driven case management of that payment system that lacked a great deal of focus on anything other than minutes of care.
When PDPM was implemented in October 2019, the industry was hoping for deeper conversations and reimbursement linked to the complexities of our patients. While gains have been made, the pandemic presented competing priorities which likely slowed our progress. Now, in 2022, we’re left questioning if the industry, and our own facilities, have effectively aligned around collaborative care.
Also challenging collaborative care is the historically siloed culture within a facility. Nursing and therapy often function from their own perspective and patient care goals without effective communication or collaboration. Restorative care and activities often work on the periphery without being included in the interdisciplinary team. Unfortunately, the resident is often even further on the periphery, with their own goals and cultural viewpoints sometimes left unexplored and unaddressed. This presentation will focus on breaking down those silos and moving toward a collaborative and integrated service model.
Integral to this model of collaboration and integration is providing effective and efficient services. To be successful in this endeavor, providers must be challenged to utilize extenders when a unique skill set is not required. Achieving this “top of license” culture often results in improved resident satisfaction and an improved opportunity to achieve resident goals as additional therapeutic practice is provided and skilled providers are left with time to address more complex interventions.
The collaborative and integrated model impacts both the quality and the sustainability of clinical outcomes. One key to achieving durable clinical outcomes is driving and inspiring a lifestyle change. Without the achievement of lifestyle change, the resident may experience a cycle of functional decline, rotating between therapy, functional decline, back to therapy, and so on. At times this cycle is even more unfortunate, including emergency room care or hospitalization. Our industry is challenged to provide effective, efficient and durable services.
It takes work to construct a collaborative, integrated model of care, delivering effective and efficient services that result in durable clinical outcomes and it cannot be done alone. To be successful, the entire IDT must be engaged and understand the benefits to the residents, their families, and your organization. Once you capture the hearts of your team, they’ll understand how to make it happen.
Dawn Greaves: You might be thinking, “That all sounds great, but how do we accomplish this? How do we truly act differently?” We’re going to touch on some of those components. We want to be able to work together to create a single view of the patient across the continuum.
We all work with patients on transitions of care. A lot of our residents, in the short stay, leave the building. They move home with home health. That seems like a pretty clear transition of care for that individual, but within your facility, within your campus, you have those transitions. We want to talk about how we address those in that little microcosm. Is there a plan for continued wellness for that individual? Fully understanding that next level of discharge is really important to how we develop that care in an efficient and effective way for that individual, whether they’re discharging to the same building or the community.
Clearly identifying those risk factors is critical to efficient and effective care and avoiding negative events. The IDT process is the key to achieving the necessary communication and collaboration. The therapeutic approach should include skilled therapy, the CNA, restorative, activities, wellness, and other services that might be available in your building to the individual. And critically, we need to know the patient’s goals. When we understand the individual’s goal and what is meaningful to them, it becomes much easier to look at the services available within your facility and determine how you want to best direct that care to pull all the pieces together.
In this process, role clarity is essential, and this can certainly be easier said than done. Patty spoke earlier to practice. Once it moves on to practice, it doesn’t take the skills of a therapist to provide that particular intervention. Therapists can feel a little threatened by that. That role clarity assists each team member in understanding the role of everyone else.
For example, if therapy is working with someone on transfers, are we instructing the CNAs who work with that individual in the queuing therapy is providing so that when they’re doing transfers, it becomes practice for the individual? Every transfer is an opportunity to practice new skills. So, role clarity and the care planning process that considers all of the support services that are available to the individual is an intentional part of the IDT.
Next plans should include intentional, patient-specific restorative activities and wellness. This can be done, and I would argue it should be done, during the course of therapy, to enhance the overall experience. In order to achieve this, ask yourself, do the folks providing restorative services understand how what they’re providing for the individual ties back to the overall care plan? Why are they providing that service? I think when residents refuse services, it’s a lot easier to approach them and discuss why they might need to participate if we can tie it back to their care plan, but more importantly, tie it back to their goals. Do your CNAs and restorative nursing assistants really know why they’re doing what they’re doing?
Next, the IDT should regularly review outcomes and assess the plan. We can make the best plan in the world, but if someone isn’t progressing according to that plan or progressing ahead of that plan, we need to look back and revise that plan as a team.
This excerpt has been edited for length and clarity. To watch the full discussion on video, please visit:
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