A change in state reimbursement and a extended evaluation of long-term care at Sampson Regional Medical Center has brought about a change to what has long been the Skilled Nursing Unit — modifications that will allow the hospital more flexibility and improved care to the patient, officials said.
The Skilled Nursing Unit and its 30 beds have given way to 40 “swing beds,” which allow a designation that can be switched from skilled (more long-term care, such as rehab) to acute (more severe ailments) and vice-versa, without moving patients or affecting the care they receive.
“We’re still committed to providing that skilled level of care for our patients,” said Sampson Regional CEO David Masterson. “We just provide it in a different manner. This is a lot more patient-centered.”
The hospital had been considering changes for some time, driven by reasons both financial and practical, evaluating the need and demand for long-term care when nursing homes in the community were better set up to deal with those residents.
“The tipping point for us was the change in reimbursement from the state, Medicare and Medicaid,” said Masterson. “The continued ratcheting down on reimbursement for hospitals really put us in a position where we couldn’t subsidize skilled nursing any longer.”
So the hospital sought out ways to provide the service. Many small hospitals provide swing beds, an option extended to hospitals in rural communities to allow those facilities to more appropriately utilize their beds.
“A swing bed is a bed that can be acute or skilled as a designation within the hospital depending on the need of the patient,” said Masterson. “It swings between acute and sub-acute. As a patient gets better, you can change the designation on the bed from a licensure perspective without having to move the patient.”
On paper, that means the patient is discharged and re-admitted, which hospital officials are required by law to tell the patient. However, from that patient’s perspective, they see no difference other than constant monitoring and medication is no longer a necessity.
“The physicians are going to prioritize their time to see the acute patients and the sicker patients, but (sub-acute patients) are in a pretty stable stage of care where they’re not getting orders changed daily … leading up to their ultimate transfer or discharge,” said Masterson.
Crunching the numbers, he said a more efficient system of long-term care was needed. As the reimbursements went down, Sampson Regional found that $160-$180 was paid a day for the skilled nursing patients.
“The hospital was losing that much on the care,” said Masterson. “When you multiply that by as many patients, it added up to half a million dollars a year.”
Of the 30-bed skilled nursing unit, typically 20 were short-term patients who were treated in skilled nursing as a step-down from surgeries or other treatment on their way home, and 10 were long-term. Half of those long-term were treated at the hospital for years.
“This became their home,” Masterson said. “Like a nursing home, we became their long-term provider, which hospitals aren’t really geared up to do necessarily.”
Nursing homes have more beds and can meet the needs of more without waste, where Sampson Regional had to meet similar standards but in a less feasible manner. One prime example was an activities coordinator position, which the hospital was required to have to accommodate its 30 patients, 20 of which did not see themselves as long-term patients. So in essence, the activities — bingo, etc — were being coordinated for 10 patients, where nursing homes could similarly hire one coordinator to have activities for 100 patients.
“The size of our facility and the beds we had really didn’t make it palatable for us to continue,” said Masterson, who also said the close proximity of Mary Gran and Southwood and the skilled beds they offer made the decision much easier. “There wasn’t an unmet need that we were trying to fill.”
Amber Cava, director of marketing and community relations for Sampson Regional, said the hospital is required to meet the needs of the community. However, there are also fiduciary responsibilities, especially when services are duplicated elsewhere.
“As a community hospital, when we do offer services that we realize we have a loss on, we evaluate that,” said Cava. “When we were losing money on providing that service and there are substantial others in the community that can provide that service … if we didn’t have that, it would be an unmet need in the community.”
‘Gives us flexibility’
As that evaluation was done, Masterson said, it did not make sense to do away with skilled care altogether because there were still enough patients transferring out of acute care that needed it.
There is a requirement that patients be treated in an acute setting for at least three days before they move down to skilled nursing. Masterson noted that patients initially treated on a acute level at other facilities, Rex and WakeMed among them, would move to Sampson when they stepped down to skilled care to be closer to home. But having not provided the initial care, Sampson Regional would not qualify for reimbursement for providing that care on the sub-acute side, so the cost of those patients’ care was a “pure loss,” Masterson noted.
Swing beds counteract that.
“It does make financial sense for us to continue to provide the swing beds and a skilled level of care for patients who are transitioning from our hospital,” Masterson said. “The swing bed is really intended for those patients who come here as acute patients, who aren’t ready to go home yet, and for us to make that transition smoother.”
Patients have complained in the past of shared rooms. Swing beds make all rooms private. The hospital’s census showed in the past that when acute patients were high in number, skilled care patients were low, and vice-versa. Now, the hospital is able to more evenly manage the same beds because there is not a concrete designation.
“It gives us the flexibility to give everybody a private room,” said Masterson. “The other thing the patients like is not having to move. Not having to disrupt the patient gives them the benefit of a consistent level of care. The nurse that knew them on the acute side is now taking care of them on the sub-acute side.”
To handle the care, employees were cross-trained and everyone — doctors, nurses, physicians, respiratory staff and others, managerial staff — had a hand in the process, which Masterson said cut overhead costs, reduced inventory and made operations more efficient.
“We had 30 beds in (Skilled Nursing), but now we can swing up to 40 patients,” said Masterson. “We haven’t opened 10 more beds, but we can designate 10 beds that were acute and are empty into skilled if we need them. So the medical patients stay on the third floor even for activities and the surgical patients stay on the second floor even for activities and rehab. It gives us some opportunities to do some new things we weren’t able to do when we had split units.”
For patients and their families, frustration sets in when a patient is constantly moved around the hospital. Wayfinding is more efficient and the paperwork is the same. It also came at little impact to current staff.
“Nobody lost a job under this,” said Masterson, noting 20 employees that worked with Skilled Nursing. “We have more staff nurses now on an acute side, between medical and surgical, because they’re also taking care of the acute and sub-acute patients.”
Families of the long-term patients being cared for in the Skilled Nursing Unit — there were five — were given three months’ notice where 30 days was required and those placements to Mary Gran and Southwood were made by the hospital. “And ironically, they didn’t meet a skilled level of care,” said Masterson. “They went into assisted living, which we don’t offer and that would even suggest they were maybe in a higher level of care than they even needed.”
While some lamented about making the move, Masterson credited the staffs at Sampson Regional and the nursing homes with accommodating the families.
“A lot of (the hospital’s skilled nursing staff) had an attachment to those patients and just cared for them for so long, it was emotional for them to help in that transfer,” said Cava. “But they had a true commitment in doing what was going to be good for that patient and making that transition as smooth as it could be.”
In the lead-up to the change, Masterson said he spoke to an official at the Office of Rural Health, who called the transition “a no-brainer” for Sampson Regional, saying it would “improve quality, improve patient satisfaction and decrease cost.” Masterson agreed, calling it the triple aim.
The new system of swing beds has been in effect for about three months. Masterson said it is a positive situation that has worked well for the hospital, especially those it serves.
“It’s really patient-centered,” said Masterson. “At the end of the day, we’re bringing the staff and the services to the patient rather than moving the patient to wherever we are. It’s not the stage of the patient’s disease they’re taking care of, it’s the patient they’re taking care of. It’s gone really well.”
Chris Berendt can be reached at 910-592-8137 ext. 121 or via email at firstname.lastname@example.org.