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Consider your options for recovery care
Services range from hotels to home health
With Medicare's 2009 change in the definition of an ambulatory surgery center (ASC), the door opened for keeping patients up to 23 hours and 59 minutes. Some ASCs now start cases later in the day, but need post-surgical recovery care of patients in the ASC or elsewhere.
If the patient stays in the ASC, you have to pay overtime or extra shift staff, plus offers meals and emergency coverage. For this reason, many managers are considering options for recovery care outside their doors. Those options include rehabilitation hospitals, home health nurses, and hotels.
When patients are having surgery at the University of Wisconsin Hospitals and Clinics in Madison, they have access to a concierge that can help them locate a hotel room for the night before and after surgery, if needed.
Members of the guest services staff know what hotel rooms are available, and they have negotiated special rates for patients, families, and visitors. "Madison hotels can be very busy because of University of Wisconsin athletic events or because of the many conventions that we host in Madison," says Shawn Arneson, concierge and supervisor of guest services. "Members of the Guest Services staff take this worry and frustration away from the patient, as we do not want them to be calling every hotel in Madison only to find out that they are full." The hospital also has three free spots for recreational vehicles that need electrical hookups.
To access these services, patients or their family members simply call a phone number or stop by the hospital's main information desk. "We are actually like a personal travel agent for the patient and their visitors," Arneson says. "We explain the options, take their information, reserve the room and give the patient the confirmation number, directions, explain amenities, travel, and shuttle options, etc."
Using a rehab hospital
Advanced Ambulatory Surgery Center in Redlands, CA, which offers orthopedic procedures, makes arrangement on a per-patient basis for post-recovery care at Robert H. Ballard Rehabilitation in San Bernardino, CA, which is a licensed, acute rehab care hospital.
"Most of our patients will utilize physical therapy in their recovery process, so the patients that we have referred/transferred to Ballard for immediate post-op care also have access to therapy," says Kathryn R. Di Stefano, MSN, RN, CNOR, administrator at Advanced ASC.
Patients or their insurance companies pay for the care, Di Stefano says. Offering this service allows the center to accept more acute cases, she says. Bilateral lower extremity fractures are one example.
"If you have two broken legs, you're not exactly 'ambulatory,' and you wouldn't usually be considered a candidate for an ambulatory surgery center," Di Stefano says. "Depending on the patient's home support system, they may require 24-hour care and cannot be discharged directly home from this facility. But they also don't require an inpatient hospital admission, just supportive care."
Sending staff nurses home with patients
Diagnostic and Interventional Sports and Spine, and Diagnostic and Interventional Surgical Center (DISC), both in Marina del Rey, CA, hire nurses to accompany patients to their homes or to hotels for what is typically 12-24 hours of post-recovery care. This service is offered for procedures such as anterior lumbar interbody fusions and also for frail elderly patients.
The nurse helps the patient and family to the car and follows them to their home or hotel. The center uses its own nurses and pays the nurse's travel time to the center and an additional $9-$14 an hour above the base rate. The center absorbs the cost of the post-recovery care staffing to provide better patient outcomes and improved patient satisfaction, says Karen Reiter, RN, CNOR, RNFA, chief operating officer of DISC.
The nurse doesn't provide intravenous or intramuscular pain medication, Reiter says. "She's there solely for education and helping the family with mobilization," she says.
One critical piece of the process is having the nurse meet with the patients and caregivers preoperatively to discuss expectations for mobilization, patient management, and restrictions, as well as the role of the nurse, Reiter says. The nurse also talks about wounds, showering, bowel care, and laxatives, she says. Reiter tries to schedule the same nurse to offer preoperative education and postoperative care. "With spine patients, if one person says one thing, and another person says another, they're not as confident with their recovery," she says. Patients also are more comfortable having a nurse caring for them after surgery that they've met previously, Reiter says. Surgeons are quick to respond to any questions from the nurses, she says.
The centers have negotiated significantly reduced rates at five nearby hotels that range from simple structures to The Ritz-Carlton. The center also has access to a condominium for patients who are staying in the area for an extended time.
The recovery care has worked out well for international or bicoastal patients who fly in for the surgery, as well as for area patients who live a long drive away, Reiter says. The centers work with a private concierge service that brings in patients from Indonesia. That service picks up patients at the airport, takes them to their preoperative visit, takes them to the surgery, and picks up their medication. The patients pay one flat rate to the concierge, and the concierge service pays the surgery facilities.
Offering recovery care gives patients "safety and piece of mind," Reiter says. Patients are more comfortable committing to the surgery, she says. "I think it opens up a bigger audience," Reiter says. (Home health nurses also are an option for recovery care. See story, below.)
Agency nurses follow patients to their homes
As outpatient surgery patients increasingly are older and have more acute procedures, some programs are finding that the best option for post-surgical care is a home health nurse.
Increasingly, outpatient surgery managers are turning to agencies such as Visiting Nurse/Hospice Atlanta, which is a home healthcare agency certified by Medicare and licensed by the state.
"Depending on the type of surgery, the nurse can do medication teaching, evaluate patient incisions -- wherever they may be -- for healing, see if there are dressings that need to be changed, and educate the patient and family on how to manage the dressing, if it's long term," says Andrea Stevenson, BSN, MPH, director of clinical development for Visiting Nurse/Hospice Atlanta. "Also, depending on the surgery, we can provide physical, speech, and occupational therapists to provide rehab to regain the functional independence they had prior to surgery."
The agency typically sees outpatient surgery patients if the patients are elderly, have elderly caregivers, or they have complex treatment or therapy. They also see patients who have had post-surgical complications and need infusion therapy to treat infections and other problems after surgery.
Nurses typically visit 2-3 times a week, depending on the physician orders. The nurse develops a plan of care with a physician and visits the patient until the goals of the plan are met. Visits typically last 30 minutes to one hour. Nurses can visit patients at hotels as well as their homes, Stevenson says.
Patients who meet Medicare eligibility criteria are not charged. Most insurance plans cover a limited amount of home health services, but prior authorization often is required and often is approved on a visit-by-visit basis.
When looking for a home health agency, keep in mind that not all of them have contracts with insurance companies, Stevenson points out.
If the post-surgical patients have a medical problem that isn't urgent, they can call the agency. "It gives us the opportunity to assess the problem, talk to a physician, and prevent hospitalization," Stevenson says. However, patients who are experiencing a medical emergency such as chest pain or uncontrolled bleeding are instructed to call 911.
What should you look for?
If you're looking for a home health provider, consider one who has expertise in the requirements your patients will have, such as infusions or wound.
"Also you want to look for a provider who has a good history of preventing admissions to the hospital," Stevenson says. Simply ask the agency for its hospital readmission rate, she suggests. Also, go to medicare.gov. Under "Resource Locator," select "Home Health Agencies" to see the Home Health Compare service. This service provides scores for key clinical outcomes and processes.
Also look for an agency that can start care in a timely manner. You also want the agency to provide a coordinator to work with your staff to transitions patients to their home in a safe manner, Stevenson says.
Communication between the two entities is key, she says. "Home health and the referring provider need to be very willing to communicate about patient status, what's going on, what issues they're having, so things can be resolved quickly to prevent rehospitalization," Stevenson says. "If a physician doesn't call us back, we're between a rock and a hard place."