November 01, 2010

We were pleased at our facility to hear that Mr. ST, a 90-year-old retired businessman, had chosen our facility for his postoperative rehabilitation. Mr. ST is prominent in our community, and even 25 years after his retirement his name and photo appear regularly in the local newspaper.

Since we are a small medical community, no one was surprised when Mr. ST chose to have his total knee replacement done out-of-state, at a world-famous medical center. Mr. ST could have chosen to have rehabilitated at home, but his wife of 55 years, Mrs. ST, has been adamant that she will not tolerate strangers in her home. The couple decided that his rehab would take place at our facility.

Social Worker: Mr. ST is being admitted from out-of-state, and neither his orthopedic surgeon, Dr. A, nor his internist will agree to follow him here. What shall we do for an attending physician?

Clinical Nurse Coordinator: I will call Dr. B, since he's an internist with a number of residents here.

Dr. B agreed to be the attending physician. Mr. ST was admitted, and Dr. B verified all the admission orders.

After 6 Days

Dr. B's nurse practitioner came to our facility on her weekly rounds. She introduced herself to Mr. and Mrs. ST – and immediately came under fire. “My husband has been here for 6 full days and Dr. B has yet to see him. He should have been here 5 days ago. He should have been here now, but instead, he sends you. That is substandard care, and we are highly dissatisfied.”

Nurse Practitioner: Dr. B rounds on his patients at this facility monthly, as required. I come here weekly between his visits and take care of his residents' needs. Physicians do not round daily at nursing homes as they do at hospitals.

Mrs. ST: Unacceptable. Tell Dr. B he's fired. We will get another physician.

Clinical Nurse Coordinator: Mrs. ST fired Dr. B, then she called Dr. C, a local rehab specialist, a physiatrist, and had him come to see Mr. ST this morning. Dr. C. wrote orders, some of which conflict with the orders that Dr. A, the orthopod, wrote, and now we don't know which orders to follow. I tried to speak to Mrs. ST about the difference in orders, but she just said “get it right.”

Physical Therapist: Dr. C just ordered continuous passive motion [CPM] settings that conflict with Dr. A's order not to overexert the new knee. Both physicians were too busy to take my call or answer my question. What if I do settings that are halfway between Dr. A's and Dr. C's?

Clinical Nurse Coordinator: But then you are following neither doctor's orders, and we will need two sets of clarifications! Can you choose whichever one seems most reasonable?

After two phone calls to Dr. A's nurse practitioner and two to Dr. C's office, the doctors agreed on settings for the machine.

Two Weeks Later

Physical Therapist: Mr. ST is making regular progress in therapy. He is working on standing and balance and is beginning gait training. In occupational therapy, he is working on upper body strengthening and activities of daily living. I anticipate that we should be able to discharge him home in 3 to 4 weeks.

Clinical Nurse Coordinator: Dr. C, the physiatrist, has been making all the day-to-day medical decisions. Once we got Mrs. ST to accept that Dr. A is in charge of surgical decisions and Dr. C is in charge of medical decisions, she seems to have relaxed a bit.

Social Worker: I'm sorry, but I disagree. Mrs. ST seems to make the rounds to each of our offices on a daily basis, complaining that his food isn't correct, that the nurse's aides don't respond quickly enough. She likes to remind us that their son is a congressman and is used to getting his orders followed quickly.

Nursing Home Administrator: (Aside): Maybe Congressman ST could get us a bit more funding so we could care for our residents a bit more easily. … Who on our team has the best working relationship with Mr. and Mrs. ST?

All: That would be Jane, the physical therapist.

Nursing Home Administrator: Well, Jane, you know that last line in your job description, the one that reads “other duties as assigned”? I need to assign you to be the concierge for Mr. and Mrs. ST. It will be your job to do everything you can to keep them satisfied with the care he receives at our facility.

Medicare Certification Meeting

Physical Therapist: Mr. ST continues to make good progress. He is now able to climb steps safely and should be able to be discharged home in about 2 weeks.

Clinical Nurse Coordinator: We have a problem here. Mrs. ST has told us that at his recent appointment, Dr. A, the orthopedist, said that he could be discharged home this week at Medicare day 20. Then he could receive in-home physical therapy three times weekly. She then called Dr. C, the physiatrist, to see him and reports that Dr. C says that he could go home – if that is what Dr. A wants. But Mr. ST should come for outpatient physical therapy five times weekly to his clinic, Dr. C says. Mrs. ST says that her husband is too weak to go home yet and that she can't care for him there. She doesn't know how she would transport him safely to Dr. C's rehab clinic.

Physical Therapist: We were planning to make our routine home visit this afternoon to evaluate his needs at home, and Rep. ST was planning on being there.

Medical Director: Why does Mr. ST need to leave this week? He's making regular progress in therapy, and he remains Medicare appropriate, doesn't he?

Social Worker: Mrs. ST has the idea that it is 20-days-and-out-the-door. I tried to explain that that is untrue, that he can stay under Medicare, just that the copay starts at day 21. She hasn't been able to be dissuaded.

Medical Director: Would Mr. ST benefit from additional skilled nursing time? How much more time?

Physical Therapy: Absolutely. About 2 more weeks of therapy would be great. We had planned the home visit for today because Mrs. ST has been adamant that she wants it done now. We can do the home evaluation today to determine what he needs at home, even if his discharge doesn't occur for several more weeks.

Medical Director to Nursing Home Administrator: Would my accompanying the physical therapist to Mr. and Mrs. ST's home this afternoon qualify as “other duties as assigned”?

At the ST Home

The house is a gracious midcentury trilevel, adjacent a golf course, well-decorated, and impeccably clean. We meet Rep. ST outside the home and enter through the garage. Mr. ST uses his walker and steps up into the family room off the garage. After catching his breath, he climbs the six steps into the middle level and sits in a kitchen chair. The physical therapist then guides him six more steps to the upper level, to his bathroom, into his bedroom, and onto his bed.

Physical Therapist: Here are my recommendations regarding home modifications to make you safer once you are discharged.

Rep. ST: My mother is implacable. She will not allow any “strangers” to care for Dad at home, and yet he seems too weak to be able to come home in just a few days. I am concerned that mother will attempt to help him physically and she will fall and be injured. What can we do?

Medical Director: Mr. ST, after climbing six steps your heart rate has increased to 104 beats per minute, which tells me that you are exerting much effort to climb those few steps. I strongly believe that you are not yet strong enough to return home safely, and I will relate my medical opinion to both of your doctors. I recommend 2 more weeks of therapy at the SNF and then discharge. After we return to the facility I will discuss my evaluation with both Dr. A and Dr. C. I anticipate no difficulty keeping you in therapy at the facility for 2 more weeks. I want you to be successful when you return home. Do you concur?

Mr. ST: If you think Dr. A and Dr. C will agree, it is fine by me.

Higher Learning

With this resident we learned that, despite their education and sophistication, neither Mr. nor Mrs. ST had understood that the patient could continue at the skilled nursing facility under Medicare Part A after 20 days, albeit with copayments. Once they comprehended that Medicare coverage was ongoing, there were no further crises. He continued in therapy in our facility and was discharged home without further incident.

I became so involved in this case as medical director because the nursing home staff was spending an excessive amount of time not on Mr. ST's care, but on addressing Mrs. ST's daily concerns. The experience reminded us that, no matter how well our interdisciplinary team works as a unit, for some residents, the only acceptable answer to a question begins “The doctor says …”

After I accompanied the physical therapist on the home visit and then called each of Mr. ST's doctors, the level of family angst plummeted. From then on, Mrs. ST went about her visits without making her usual complaint rounds in the offices of the administrator, the director of nursing, the social worker, the nurse manager, and the therapist.

Once again we were reminded that each resident has individual needs and demands and that to meet those demands requires individual care. Sometimes it even requires a physician's house call in order to satisfy the demand of the patient, his family, and all of his personal physicians and surgeons.

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