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In an industry plagued by problems, one nursing home turns itself around

From the September 2000 ACP-ASIM Observer, copyright © 2000 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

BALTIMORE—On a warm afternoon last spring, the mood at Levindale Hebrew Geriatric Center & Hospital was decidedly upbeat. The nursing home was joining a nationwide effort to overhaul long term care, and a crew from Maryland Public Television was on hand to cover the facility's new approach.

For Susan M. Levy, MD, Levindale's vice president of medical affairs and medical director, the media attention was particularly sweet. When she signed on as part of a new administrative team two years ago, the facility suffered from poor cash flow, a revolving door of medical directors and plummeting morale. To make matters worse, HCFA had slapped Levindale with a $500,000 fine for billing fraud just months before she arrived.

Today, however, Levindale has undergone a dramatic transformation. Staff turnover has been cut in half and the facility has converted its troubled finances to a modest surplus. While Levindale, like nursing homes nationwide, still copes with a tight cash flow and a tough regulatory climate, its administration and staff are forging ahead with new innovations.

"We're trying to build a new culture," Dr. Levy tells a television reporter. "We're trying to focus on a new approach to care that involves everyone here, and so far it's gone in the right direction."

An industry in trouble

In 1998, the situation at Levindale was so critical that one administrator says the facility measured cash "in minutes, not days." Staff turnover had reached a crippling 50%, and distrust between physicians and staff ran high. When Levindale was fined for improperly submitting Medicare claims and forced to undergo a five-year mandatory compliance program with a yearly independent audit, it seemed to be the highest hurdle of all.

To be fair, Levindale's problems were not unusual. Medicare cuts from the 1997 Balanced Budget Act have hurt the industry, leaving many nursing homes reeling. Nearly 10% of the country's 16,000-plus nursing home facilities have declared bankruptcy, a figure that approaches 25% with for-profit facilities. Nursing homes must also cope with regulatory agencies that one Levindale administrator described as "increasingly hostile," and many face an annual staff turnover rate of 90%.

What makes Levindale unique is how it has responded to those challenges. While nursing homes nationwide have sought new revenues by diversifying their services, Levindale offers an unusually broad range of what Dr. Levy calls "soup-to-nuts care." The facility has a 146-bed nursing home, a 24-bed subacute unit, a 26-bed dementia unit and a 96-bed chronic care hospital, all of which are overseen by Dr. Levy.

Financially, Levindale's chronic care hospital benefits from a fluke in how Maryland hospitals are paid by Medicare. HCFA granted the state a waiver allowing it to set its own Medicare and Medicaid reimbursement rates for hospitals, including chronic care hospitals like Levindale's. While HCFA has cut payments to skilled nursing facilities for extended care, Levindale's chronic care hospital continues to receive the more generous state-set reimbursements for its services.

That means that Levindale earns a modest profit on its chronic care patients, many of whom are on ventilators or receiving rehabilitation services. While nursing homes in Maryland and throughout the country are shuttering their extended care services because of low reimbursement, Levindale's chronic care census since 1998 has risen from 65% to 95%. The facility has gone from losing money in the 1990s to a 10% surplus today.

That surplus helps Levindale subsidize its other services, like the subacute unit that is losing $150,000 a year because of Medicare cuts and the nursing home in which 80% of the residents depend on Medicaid.

Levindale has also used some of that surplus to raise aides' salaries and offer new nurses signing bonuses, a strategy that has helped reduce staff turnover. The money also means the facility does not have to turn away subacute patients whose medications may cost the facility more than HCFA pays, a dilemma that many nursing homes face.

And finally, the surplus has given Levindale the money to take part in the initiative that is the focus of today's media attention. Levindale has become one of only 200 nursing homes nationwide to register in a program called the Eden Alternative. As an Eden Alternative facility, Levindale will work to give its nursing home residents a more nurturing environment and its staff more flexibility in resident care. The surplus is vital to the project because it will help pay for extensive training required for both administration and staff.

As Dr. Levy explains on camera, a goal of the Eden program is to shift from a medical care model—where there's "a pill for whatever ails you"—to one focused on social and emotional well-being. "Boredom and loneliness are what's epidemic in nursing homes, not disease," she says.

Living in an Eden facility, residents will be able to raise pets, garden in wheelchair-accessible greenhouses and organize into smaller "families" for more companionship. They may also need fewer drugs and have fewer complications because of the program, Dr. Levy tells the reporter.

"Happier patients," she says, "have better outcomes."

Defying stereotypes

Happiness is one of the last things that come to mind when most people think of nursing homes. It's a situation that Dr. Levy says that the industry has in some ways brought upon itself.

She acknowledges, for example, that some harsh stereotypes of medical directors have been true all too often. In the past, many physicians chose nursing home work as a pre-retirement post, she points out, or when they couldn't find jobs elsewhere.

But physicians like Dr. Levy like to think of themselves as a new breed of nursing home doctor. The 45-year-old geriatrician first began working as a medical director in her 30s. After graduating from the University of Maryland School of Medicine, she served a geriatric fellowship at New York's Mount Sinai Medical Center. She is quick to point out that she still thrives on the challenges of treating the elderly.

"I find much more of the art of medicine in trying to care for these folks," she says, walking through the lobby and past a wooden cage where a pair of canaries—evidence of the Eden project—keep up a constant serenade. "You can go to an internal medicine textbook and find the chapter on diabetes, on heart failure and on COPD, but nobody's written the chapter on the patient with all three diseases and how to manage them at the same time."

Dr. Levy defies other stereotypes. She is among a small but growing number of medical directors who work full time (about one-third nationally). And like many of her colleagues around the country who have moved from overseeing compliance to hands-on medicine, Dr. Levy spends half her time in clinical care.

As she opens the double doors onto a nursing home floor, an aide immediately brings a 70-year old man with advanced metastatic cancer to her attention. Dr. Levy examines the man in his room, suspecting urosepsis after he complains of bladder spasms. An aide takes the patient's temperature; it is 104. Dr. Levy returns to the nurses' station to order a blood culture and an IV antibiotic.

"Traditional nursing homes would be calling an ambulance right now," she says. Though she's given the patient the option of transferring to a hospital, he wants to stay in his room. Because she has three full-time internists and four physician assistants on her staff, Dr. Levy has to transfer far fewer residents for acute care, which saves money for both the nursing home (in ambulance charges) and for Medicare.

Another patient has complained of discomfort caused by zoster, Dr. Levy discovers after she examines him. She writes an order for famvir, a drug she prefers over acyclovir because it's administered less often. Dosing frequency is a key concern, she explains, because aides may spend a half hour giving a patient medications.

Dr. Levy is also the attending physician for 70 of the nursing home residents, whom she examines at least once a month. Today, she goes in and out of a dozen rooms, listening to chests, checking swollen ankles and always asking about children and grandchildren. Out in the hall, a patient tells Dr. Levy that she doesn't remember eating lunch. Dr Levy takes her hand and, their fingers entwined, slowly guides her to a recreation area.

Once she's settled the woman down with a snack, she admits that there are days when her patients' dementia and incurability can get her down. "As you get older, you realize that this could be your future." But she thrives on what she calls "little rewards": caring in-house for someone acutely ill, seeing a frail patient gain weight, helping guide a resident through a comfortable death.

Shepherding staff

While patient care provides Dr. Levy with some of her most satisfying moments, administration remains a major part of her job.

Compliance, for instance, is always a concern. Dr. Levy meets once a week with the director of nursing to look for "red flags"—like a patient's high number of medications—in the quality indicator reports that Levindale shares with HCFA. Compliance is also a major topic at her weekly staff physician meetings, the monthly board orientation lunches she attends and her quarterly integrity meetings with senior staff.

Emotionally difficult situations are another large part of Dr. Levy's administrative duties. Back in her office, she returns a phone call from the nurse who heads Levindale's hospice program: The daughter of a patient with advanced Alzheimer's and cardiomyopathy has requested hospice care. It is fortunate, Dr. Levy tells the nurse, that the daughter has power of attorney, because another sibling insists their parent should get full-code care. It is a common conflict that she deals with as an attending physician and as chair of Levindale's ethics committee.

She also returns a call from admissions. The nursing director of the chronic care unit doesn't want to admit a 16-year-old who has suffered a C2 injury and is on a ventilator. Dr. Levy reminds admissions that the facility has a JCAHO-mandated age cut-off of 18. Once she's off the phone, though, she admits that even without the cut-off, she would defer to the nursing director's request.

"Caring for such a young patient takes a heavy toll on the nurses who are used to working with geriatric patients," she says. "The families of young patients are devastated, and it's much more stressful."

The phone calls underline another key factor in turning around morale and performance at Levindale: developing teams that include all kinds of staff. "There is a reason why they are called nursing homes, not doctoring homes," Dr. Levy says. "Geriatricians often think that we always need to be the boss, but being able to respect and tap into other disciplines is key."

She lobbied hard when she first arrived to hire an enterostomial nurse to advance wound care and strengthen the role of nurses throughout the facility. She drew physicians, nursing staff and administrators together for clinical care teams on wound management and pain assessment. She charged Levindale's pharmacists with developing and running in-house drug management programs and organized weekly meetings on admissions, transfers and discharges. And as she worked with different teams and committees, she made sure that nurses and aides had leadership and input.

She also admits that her style of hands-on care and her presence in the halls has helped turn around the distrust between physicians and staff that she found when she first arrived. "In some units there are still some bad memories," Dr. Levy says, "but I've done a quick and dirty internal survey to get some feedback for the physician staff. Now we're working well together."

Those efforts have paid off with a much more stable staff. Turnover has been cut in half in the past two years and now stands at 25% among general staff and 15% among certified nurses.

"We used to have aides taking second jobs to support themselves," Dr. Levy says. "They also felt cut off from decisions affecting patient care." Not giving more money and input to the people within nursing homes who provide residents' most consistent care "are industry-wide problems," she continues, "that need to change."

Moving forward

While Levindale's situation is stable for the moment, finances are an ongoing concern. The facility's administrators are discussing contingency plans if Maryland lowers its state-set hospital rates, as is rumored. While Dr. Levy has never had to turn patients away because of low reimbursements, she admits that it's something she can't rule out. "There may come a time when we have to say, 'We can't afford to take this patient, even as a nonprofit.' "

For now, however, Levindale's administration and staff are focused on a more positive future. It will take at least a year to fully implement the Eden program, and Levindale has other plans. It is raising funds to build another nursing home campus outside the city in Baltimore County, and Dr. Levy is busy developing a community outreach program to establish home care and house call services to nearby assisted-living apartment complexes.

"We're bringing more people from the community into the nursing home as part of the Eden program," she says. "Now it's time for us to branch out into the community."

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