Today's long-term acute care patients are faced with the challenge of overcoming multiple active medical problems during a comparatively short length of stay. Preparing these patients for the point of discharge puts a strain on health care professionals, time and resources.

"As therapists, we need to teach patients the safest way to return home during the time we have. With good communication, family teaching and trust in our fellow professionals at other levels of care, we can get the best outcomes," explained Sean Hannigan, PT, MS, rehabilitation clinical supervisor with Shaughnessy-Kaplan Rehabilitation Hospital (SKRH) in Salem, MA.

The staff at SKRH has adapted to treating sicker patients with shorter lengths of stay by co-treating with other disciplines, expanding equipment resources, emphasizing communication between all disciplines and incorporating the use of more assistants and aides, according to Molly Gerson, MSPT, senior PT, SKRH.

SKRH is a 120-bed long-term acute care hospital (LTAC) with a separately licensed, 40-bed transitional care unit (TCU) on site. SKRH treats more than 2,000 patients per year in a variety of inpatient programs including neurology, orthopedic, cardiac, ventilator, pulmonary and complex medical. The average length of stay in the LTAC unit is 25 days.

Inside Effort

"We have improved our knowledge and delivery of care at every level and in every department," Hannigan said. "We made patient care more efficient and added programs where needed."

SKRH has developed a hospitalist program comprised of physicians who meet with the team daily to give input into each case. The hospitalists are available around the clock and know each nurse, therapist and family member which allows them to be responsive to all questions.

Similarly, the hospital's nursing department employs two nurse educators who continually in-service and update staff on new techniques and equipment that SKRH is using to care for sicker patients.

"These specialists are vital in helping nurses and therapists become competent when dealing with patients with complications such as peritoneal dialysis or a chest tube hooked up to wall suction," Hannigan observed. "Years ago, many of these patients would stay in an ICU, but now we are able to care for them here."

The therapists commonly use standing frames, tilt tables and a LiteGait system to deal with sicker patients who as a result require more physical assistance. For vented patients, the therapists use portable ventilators for gait training.

The PTs are trained to complete clinical competencies in ambu (a mechanical assistive breathing device) and suctioning for patients who are vented and have tracheostomies.

The rehab department has played a large role in educating staff members on how to safely handle sicker patients. The hospital has increased its fleet of Hoyer-style lifts and standing transfer aides. The hospital plans to outfit some of the patient rooms and gyms with ceiling lifts to help staff deal with heavier patients and give the patients access to participate in more rehab activities.

"We have increased our reliance on supportive personnel such as PT aides and nursing aides and use more co-treats between PT and OT to accommodate these patients," Hannigan said.

Likewise, Gerson has begun using the PT aides more for individual therapeutic exercises or to reinforce functional training as well as for co-treating.

At SKRH, the PTs rotate between acute care, LTAC and TCU/SNF so they understand the various levels of care and can treat patients at each level. SKRH is attached to an acute care hospital-NSMC Salem Hospital-where patients can have any number of medical tests, image studies and procedures, all without being discharged or even needing to go outside.

Modified Approach

For therapists, the goal is always to return patients to their prior level of function. But patients who qualify for an LTAC level of care are very sick and typically present with multiple co-morbidities.

At the point of admission, rehabilitation is only part of these patients' needs. The initial priority may be to improve kidney function or bring congestive heart failure under control.

"We hope that a patient's medical recovery matches his physical recovery and we can return him to home," Hannigan said. "Unfortunately, patients can often stabilize medically and still require weeks of rehab to reach their goals."

Gerson views treating sicker patients with multiple co-morbidities as a practice in patience. "Instead of always expecting tasks to be completed, I break the tasks down into pieces to make a session more successful. Once again, learning to change expectations is key to developing a plan and setting goals."

According to Hannigan, the therapists must start slowly with patients who are arriving at SKRH with multiple co-morbidities and more complications. The initial therapy session may just be 15 to 20 minutes if that is all the patients can tolerate.

"The role of rehab increases as patients become more medically stable. The challenge is being patient during the process," Hannigan explained.

An initial goal for these patients can be to tolerate being Hoyered up to a chair for 30 minutes and using isometric exercise, ace wraps and compression stockings to simply maintain blood pressure.

"Basic PT treatments are clinically appropriate and rigorous for the low-level patient and I have realized that every session doesn't need to include high-level, out-of-bed activities to be effective for the recovery of the patient," Gerson shared. "I focus on body mechanics and proper form, ultimately making the patients and their caregivers safer and more efficient."

Point of Discharge

The safety of the patient seems to be the biggest concern for family members. "The primary caregiver is involved in the PT plan of care from the time of admission so at discharge there are no surprises," Gerson shared.

Gerson encourages caregivers to communicate concerns with all disciplines including the physician. "I also remind caregivers that taking care of themselves is as important as the care they provide for the patients," she said.

The therapists educate families on how to care for a loved one at home. "We often refer our patients to home PT," Gerson said. "Prior to discharge, we ensure that the proper equipment is in place and we provide written education to the patient and family."

The family education includes what home exercises to perform, how often to walk and how to help the patient complete activities of daily living. "I spend more time collaborating with the rehab team since a solid plan of care is crucial when time is limited," Gerson shared. "I have learned to focus on involving the patient immediately in their own care and I issue 'homework' regularly."

The department recently treated Russ Kuhn, 80, who was admitted with respiratory failure as a result of complications from a gastric volvulus.

In addition to being extremely hard of hearing, Kuhn has a past medical history that includes deep vein thrombosis, pneumonia, atrial fibrillation, stroke, anxiety, rheumatoid arthritis, chronic obstructive pulmonary disease and ­hypertension.

Kuhn participated in six weeks of therapy including functional transfer training, strength and endurance training, use of the standing frame and several sessions of therapeutic exercise. 

Kuhn plateaued at a two-person level of assistance. His family, including two sons and a wife, is extremely supportive and decided to take him home.

The department took the patient and his family through extensive family teaching. Prior to discharge, family members were asked to perform all care that the patient needs in front of the therapist to ensure it is done safely.

Kuhn is currently doing home PT and other services to carry through his goals at home.

SKRH's rehab team is in the position now, much like in acute care, to recommend the appropriate next level of care, whether that is skilled nursing, inpatient rehab or home care. The therapists ensure that a thorough discharge is completed for the therapists who will continue the patient's care.

"When patients move from our LTAC floors to our TCU/SNF, we regularly have conversations with the PTs on that unit and even introduce them to the patients," Hannigan said.

Everyone Deserves an Education

"Educating the patient and his family and friends is not only important, it's the key to success," Gerson imparted. "If a patient is not motivated to participate in his own recovery, the success of his outcome suffers. Likewise, support from family and friends can help the patient succeed."

Gerson has learned to involve the family and friends of these patients earlier on in the process. "It's important to communicate often and be precise in your documentation," she said.

The whole team at SKRH meets with family members to go over each aspect of the patient's care, address questions and ease their minds. "There is a general overwhelming feeling that happens to most family members, especially after a loved one has spent months in the hospital," Hannigan said.

For example, a nurse will review medications and complete diabetic management teaching; the respiratory therapist will review MDI administration or tracheostomy care; the social worker will refer the family member to available community services; the case manager will set up VNA services and explain what physicians need to be followed-up with and the therapy team will bring the family member to a therapy session prior to discharge.

"We need to educate families and patients that there may still be a long road ahead," Hannigan shared. "We are honest by letting them know that the patient won't be able to spend hours in the gym initially, and that they may even need another facility before returning home."

When a patient is returning home at a different level than before the illness, such as at a wheelchair level, the therapists complete home visits. SKRH uses a wheelchair van to take patients home prior to discharge so a PT may assess each room of the home to ensure safety and accessibility.

In addition to housing long-term acute care and transitional care units in the same building, SKRH has access to its sister hospital, Spaulding Rehabilitation Hospital, and many of the patients who discharge to the community receive VNA services from Partners Home Care.

"We have close relationships with these organizations and our therapists have begun educating each other," Hannigan said. All in-services and continuing education opportunities are available to therapists at each institution. They have pooled the clinical and patient resources available on the Internet for patient groups such as neurology and orthopedics so all of the therapists have access.

"I think the thing to learn is how to maintain consistency across many levels of care as no patient can stay in one place for as long as we all may like," Hannigan shared.

Rebecca Mayer is senior regional editor of ADVANCE and can be reached at rmayer@advanceweb.com