Long-Term Care Survey Alert

Hint: Counter false expectations, respond to this often unrecognized psychosocial reality.

An immediate jeopardy citation or worse often starts with a phone call from a disgruntled family member to a government agency or a plaintiff attorney who posts his number on a billboard. And even if the complaint lacks validity, the facility often faces a world of trouble that it might have prevented by nurturing and partnering more with families.

Take-home message: Facilities that work proactively with families not only head off major survey and litigation woes, they also can help families heal, and develop a reputation in the community for being family friendly. "Improving family satisfaction may be one of the most business important decisions you'll make," said psychiatrist Jules Rosen, MD, who presented on family stress in transitioning to the nursing home at the October 2008 American Health Care Association's annual meeting.

Meet with the resident and family members within 48 to 72 hours after admission to discuss their expectations, medical concerns, discharge planning, and therapy needs, advises Shehla Rooney, a physical therapist and principal of Premier Therapy Solutions in Cookeville, Tenn. She finds that residents/families oftentimes have unanswered questions from the hospital or may have been unhappy with the hospital care. Hearing about these issues can help the SNF resolve any care concerns and also avoid the hospital's mistakes, says Rooney.

Another problem: The hospital may have set unrealistic care expectations for the family -- for example, using siderails or restraints to prevent falls, which can cause regulatory problems in the nursing home, notes Mardy Chizek, a legal geriatric nurse consultant and nurse practitioner with Chizek Consulting Inc. in Westmont, Ill. And "if you don't set expectations for families, they will set them for you," she cautions.

Pressure ulcer example: Chizek hears families say no one told them that their loved one has a wound. Or the hospital staff may have told the resident's family that their loved one has a "little lesion," which the family never inspected. And then the family first sees this "little lesion" upon the resident's admission to the nursing home, except it's actually a gaping stage 3 or 4 pressure ulcer, she notes.

Proactive approach: Use consistent terminology in referring to the resident's "wound" -- for example, pressure ulcer, if that's what the clinician has diagnosed, Chizek advises. Always include the family, if available, in the first dressing change at admission, she adds. "Show the family what the wound looks like and how the facility is dressing and caring for it, including turning/repositioning, hydration, nutrition, etc. [Also] talk about the diagnosis or etiology of the wound." If it's an arterial ulcer, show the family how the foot is cold and has no hair due to poor blood flow, for example.

Also, "the physician should explain the medical treatment plan," adds Chizek.

Important: "Families need to know the normal progression of aging versus that of a disease state so they understand the differences," advises Francis Battisti, a social worker in Binghamton, NY.

Families may experience even more severe stressors when their loved one transitions from home care to the nursing home, Rosen noted. Yet, naturally, the family member, often a spouse who's been providing heavy care for her loved one, may expect to feel better, not worse, after the nursing home placement. And guess whom the person may blame for her stress and grief? That's why it's important to educate the family about how people tend to respond to nursing home placement and suggest coping strategies, such as taking time to do things they enjoy, Rosen emphasized.

Learning tool: Rosen played a video made by Fox Learning Systems (Pittsburgh, Pa.) of an interview with a woman who placed her long-time husband with dementia in a nursing home. The woman's frank comments about her true feelings and overwhelming grief provided an inside look at how family members might feel. This kind of video can also help staff empathize with what family members are going through, Rosen noted.

Also take a close look at the facility's support and educational offerings. Support groups tend to have a bad reputation because they become "b...ing sessions," Rosen cautioned. One AHCA conferee noted that her facility had trouble getting families to attend evening educational offerings. The solution, opined Rosen: Serve food -- for example, cater supper.

As the family settles in and can better attend to new information, conduct a series of sessions on various topics, such as advance directives, Medicare and common care topics. Teaching families how Medicare works can help prevent them from calling the 1-800 Medicare line to complain their resident didn't getting a full 100 days of skilled care, Rosen pointed out.

The bottom line goal: You want to create a sense that you're in this together with the resident and family, Rosen stressed.



Collaborate With Residents/ Families About Hospitalization.

Everything may be going well with a family until the resident requires hospitalization -- a potential fork in the road that you can prepare for ahead of time.

A key question: Is the patient or his decision-maker willing to accept simple evaluations and treatments for potential common causes of symptoms? asks Bruce E. Robinson, MD, chief of geriatrics at Sarasota Memorial Hospital in Sarasota, Fla. "If not, the person will have to be hospitalized. You can't assume a frail elder with a cough has a cold or bronchitis -- or that a little stomach pain is indigestion," says Robinson. "If that symptom(s) turns out to be a deadly condition, that's when people start second guessing the physician's and facility's care," he adds.

"Looking back, people will say you should have been able to figure out what was wrong before you did."

Solution: The physician and facility should educate the resident and his family about the options and try to get a consensus about what they want to do. For example, Robinson lets the resident/family know that if they want to take advantage of every treatment opportunity, then the resident has to go to the hospital.

Caring can spare you: People tend not to sue providers whom they like, even if there's a negative outcome, Rosen pointed out. That's one reason he goes out of his way to let residents' families know through words and actions that if something goes wrong, it's not because he doesn't care.