The purpose of this paper is to describe a nursing liaison program developed between a rehabilitation center for the aged and an acute general hospital. This program has improved the continuity of care for the center's residents, has had a positive influence on nursing care delivery in both institutions, and has been proven to be cost effective.
The Hebrew Rehabilitation Center for the Aged
The Hebrew Rehabilitation Center for the Aged (HRCA) is a 725 bed geriatric residential chronic disease hospital located in Roslindale, Massachusetts. The services offered the elderly range from independent ambulatory care to intensive rehabilitative care for mental and physical impairment. Living arrangements, nursing care and paramedical care are provided based upon the resident's level of functional ability necessitating a periodic review of the resident's condition with the option of housing him in the area most suited to care for his needs. There are 17 nursing units at HRCA offering five graduations in nursing care.
The average age of an HRCA resident is 85 years and the average length of stay is 3.5 years.
HRCA enjoys a close affiliation with Beth Israel Hospital, Boston, where residents of HRCA are serviced for any necessary diagnostic tests, surgery or medical treatment not provided on the premises of HRCA. The affiliation is further enhanced by having all HRCA physicians on the staff at the Beth Israel Hospital.
The Beth Israel Hospital
The Beth Israel Hospital (BIH), Boston, is a 452 bed, Harvard affiliated teaching hospital. Historically it began in the early nineteen hundreds when the number of immigrants from Europe was great and there was an urgent need to provide these people with inexpensive, accessible health care. Many of these immigrants were Jewish and with their strict dietary and other religious customs appropriate health care was difficult to obtain. Out of their need the Beth Israel Hospital grew from a dispensary for the indigent to the modern hospital thai it is today. Its ties to the Jewish community are still very strong.
The Liaison Program Between the Center and the Hospital
It was logical then that when the Hebrew Rehabilitation Center for the Aged developed it would negotiate with the Beth Israel to provide for the acute hospital needs of its residents. A formal proposal was developed and an agreement between the two facilities was signed in June 1965. This agreement has been strengthened by the nurse liaison program we will be describing in this paper.
In May of 1974, the Nursing Continuing Care Coordinator at Beth Israel Hospital, and the Assistant Director of Nursing at the Hebrew Rehabilitation Center for the Aged, realized that these two affiliating agencies had no tangible nursing link,· There was virtually no formal or informal lines of communication or mechanism for continuity of care between the two nursing departments. They set out to bridge this gap through the implementation of a program that would facilitate appropriate and continuous nursing care of the resident while at the BIH and upon his return to HRCA. The first order of business was to compile information that could be instrumental in planning for the appropriate placement and hence the appropriate type of nursing care for the resident upon his return to HRCA. In August of 1974 this project was implemented. Beth Israel Hospital nurses provided an up-todate assessment of the resident's condition and functional ability and projected a discharge date. This information was conveyed by the Nursing Continuing Care Coordinator at BIH to the Assistant Director of Nursing at H RCA on a weekly basis.
The functional assessment tool utilized, categorized nursing care requirements into four progressive levels of care. The nurses at both facilities were oriented to the use of the tool. In that way, the same criteria was used by BIH nurses and HRCÄ nurses to assess and categorize the condition, functional ability, and level of nursing care required (Table I).
After the reporting mechanism was established and appeared to be running smoothly HRCA began its first four-month study of the reported information. The information seemed to be accurate; but without systematically reviewing the reports and comparing the projected hospital discharge dates with the actual dates patients were readmitted to HRCA, we could not be sure. The accuracy of this information was important because the HRCA Committee utilized it in planning to have a bed available on the projected hospital discharge date. If this information was not accurate there was no point in going to the time and trouble of obtaining it. The results are reported as follows.
Accuracy Study - Part I
Objectives: To assess the accuracy of the projected date of readmission to HRCA and to therefore give an indication of the value of this Liaison Program to HRCA in their decision making regarding internal placement and admission.
Methodology: Reports of the projected date of readmission were compared to the actual date of readmission for a period of four months. Fifty-one residents were studied. A readmission date of one day before or after the projected date was considered acceptable.
Findings: It was found that the projected readmission date as reported by BIH and as utilized by HRCA were 92 percent accurate. An explanation of findings is given in Table II.
The positive results from the first study lead naturally to a second study. We now knew that 92 percent of the projected readmission dates to the HRCA were accurate. The next question asked was how accurate was the information concerning the patient's functional abilities while in the hospital. This information was important because HRCA used it to determine what level of care the patients would require when they returned to the center and therefore which area they would reside in.
Accuracy Study - Part II
Objective: To assess the accuracy of the reported condition and functional assessment of residents readmitted to the HRCA from BIH. This information will give the HRCA an indication of the value of the liaison program in the placement of residents upon their return.
Methodology: Condition and functional assessment reports submitted by BIH were compared to condition and functional assessment reports of HCRA at the time of readmission. A period of no longer than one week between obtaining these two reports was considered acceptable. The resident functional assessment tool presently utilized by HRCA were the accepted criteria for evaluation by both HRCA and BIH.
Data for HRCA assessment were obtained directly by the assistant director of nursing at HRCA - assessment of residents as well as indirectly through interviewing charge nurses at HRCA. This is consistent with BIH's data collection methodology. Over a three month period, 43 residents were studied. A deviation in any of the categories of the resident functional assessment tool was considered unacceptable because of the potential for inaccurate calculation of nursing care required.
Findings: It was found that BIH reports as utilized by the HRCA committee when compared to HRCA readmission reports were 86.2 percent accurate. Of the 43 residents studied, 36 reports were totally accurate and seven reports were inaccurate in at least one category. The findings by category of assessment are shown in Table III.
The condition and functional assessment reports utilized by the HRCA in assessing appropriate placement at the time of readmission are 86.2 percent accurate. These reports are 100 percent accurate in all categories except mentation and behavior which have an 86.2 percent and 91 percent accuracy rating respectively. The discrepancies in ^nese areas may be due to any or all of three factors: (1) varying standards and validation techniques for assessing mentation and behavior between HRCA and BIH nurses; (2) difference in mentation and behavior temporarily produced by transferring from one environment to another and unfamiliar surroundings; (3) difference in mentation and behavior temporarily produced by the illness itself.
The data collected was further examined in the areas of mentation and behavior. Of the ten discrepancies found in combining both categories only two were a result of the hospital nurses assessing the patients to have a lesser degree of functioning than the HRCA nurses. The remaining eight discrepancies could probably be attributed to less familiarity with dealing with elderly patients on the part of the hospital nurses. In other words, behaviors that the Center nurses would not consider problematic might be considered very problematic to hospital nurses.
HEBREW REHABILITATION CENTER FOR AGED
EXPLANATION OF FINDINGS
FINDINGS BY CATEGORY OF ASSESSMENT
The recommendations that the Liaison Program was valuable and that information being presented was as accurate as possible was a direct result of these accuracy studies. The Hospital and the Center had factual data to support their feelings that the program was worthwhile.
Benefits to the Center
There has been a definite benefit derived from this Liaison Program to HRCA in terms of bed utilization. The weekly reports of hospitalized residents' condition, functional status, and projected day of return makes the allocation of the appropriate bed more accurate and more expedient than ever before.
The implications of this are two-fold:
1. This means that tax payers money need not be wasted in keeping beds open unnecessarily.
2. This also means that the resident returns directly to the bed in HRCA in the area most suited to caring for his specific needs. A right the resident deserves! Eliminated is the possibility of a resident being traumatized by returning to an inappropriate placement at HRCA and then when the staff assesses his needs, moving him to the appropriate place.
As we began simultaneously to work towards improved communications between the nurses at both facilities regarding the management of nursing care prior to admission to the hospital, during hospitalization, and for continuing care after hospitalization, some definite changes took place.
At HRCA, a group of head nurses developed, pretested, and implemented a new Interagency Referral Form to inform BIH nurses of the details of the management of nursing care prior to admission. As a result, a complete assessment of all areas of functional ability and disability, current nursing care programs, special problems or needs, and suggested approaches accompany the HRCA resident to BIH when he is admitted.
Benefits to the Hospital
The benefits of the liaison program to the BIH are not as easy to identify. One major reason for involvement with the HRCA was that, unlike many patients being admitted to the hospital from nursing homes, the Center was always ready to accept their patients back when the need for acute hospitalization was resolved. To the BIH this meant no extended waits while the Social Service Department scoured the city for a new nursing home bed. For some patients this wait can actually extend to a month or two. During that time period an acute hospital bed is being occupied by a patient who does not require that high level of care. In the meantime it ties up hospital beds that might be acutely needed by another member of the surrounding community. So, we at the hospital felt, if providing the center with patient information on a weekly basis would facilitate the HRCA in their attempt to accept patients back immediately, it was well worth our effort.
Up to this point we have focused upon the benefits to each of the institutions, but more importantly there were obvious benefits to the patients. These elderly people returned to their familiar environment (the Center) without an extended hospital stay. No one wants to be detained in a hospital not geared to meeting the total needs of the elderly; certainly not when you do not need this level of care. For one thing there are no recreational or other programs in an acute hospital to fill the elderly person's social needs. At the Center there are such programs and friends - a whole life style especially geared to the older person.
The hospital's nursing staff was also affected by the Liaison Program. They were being asked about the condition of these patients every week and the interpretation was made that the Center was interested in what was happening to its residents. This show of interest encouraged the nurses to communicate with the Center directly if they had any nursing questions about a resident. For instance, if a patient was difficult to handle in the hospital the staff nurse felt free to call the Center to ask how their nursing staff worked with this particular patient. Or how did the Center nurses deal with a blind patient? Was there a system that the hospital nurse might use to make things more consistent for this handicapped patient? Intercommunication between the Hospital and the Center has answered such questions. In effect the hospital nurse learned more about caring for the elderly patient, and ultimately this made the patient's hospital stay more comfortable.
The increased interest on the part of the staff nurse could also be seen in the written communication between the BIH and the H RCA. In an independent study of interagency referrals for a four-month period, the Medical Records Department at the Center found that all of the written nursing information coming from the BIH was complete. The nurses were more invested in sending complete information because they felt the HRCA was concerned about what had happened to their residents during hospitalization.
In summary this paper has described a nursing liaison program between a center for the aged and an acute care hospital. The key to this program has been communication between the nurses at both facilities utilizing a common assessment tool. This program has both improved continuity of care for the elderly clients involved and has proved to be cost effective.
HEBREW REHABILITATION CENTER FOR AGED
EXPLANATION OF FINDINGS
FINDINGS BY CATEGORY OF ASSESSMENT