Thursday, June 11, 2009

The New Outback of Medicine

It's 4AM at one of the tens of thousands of long-term care facilities (sometimes euphemistically called "rehab centers") that dot the country. The silence is punctuated by a cryptic announcement from the public address system:
"Nurses, it's time to look out the window."
At 6AM, another announcement:
"Nurses, it's time to look at the ceiling."
Later, another:
"Nurses, it's time to look out the door."
All day, all night, 24-7-365.

This is not a reference to psychological wellness for nurses, but rather state-regulated instructions for pressure sore care that are happening now in the new outback of medicine: long term care facilities.

One of the key strategies of current health care reform to control costs are "bundled payments:" a single payment to hospital systems based on national norms for treatment that place the onus to save costs on the facilities and physicians. Through "comparative effectiveness research" strategies it is argued, "best practices" for care can be developed and disseminated to reduce costs. As these under-funded "bundles" are deployed, hospital systems will increasingly look to ways to shorten length of stays to remain fiscally solvent. As a result, patient census at long-term care facilities will only grow.

And from this group research strategy, comes group care.

Just like it's happening now.

"Nurses, it's time to look out the window."



Keith Sarpolis said...


Having recently been confronted with the possibility of my mother and father in law possibly ending up in nursing homes, it is the most scarey part of the medical system from my perspective. Too much of our resources are directed to the acute care side with too little brought to bear on caring for people discharged to these facilities. It is difficult for me to see my patients in these settings due to time and poor reimbursement and I have yet to hear of any specialist who goes to visit their patients in nursing homes, so the logistics of careful follow up after an acute illness are difficult. Possibly it is a good idea to bundle these payments. As you know, the instituition where you ply your trade not long ago closed its in house skilled nursing facility claiming it was underutillized (despite the fact I could never get my patients into the unit because it was always full). Such a bundling will force hospitals to think twice about how rapidly they push people out of the acute care setting. The prior system created an out of sight, out of mind mentality where the risks of earlier discharge were not weighed against the benefits of continued close observation in the hospital.

Rogue Medic said...

As an insomniac, it causes me to wonder about the effect on the sleep of these patients. I realize that this is because many are bed ridden, so they will make up for the sleep during the day, but there probably is other stress-related harm from this.

Anonymous said...

As a nurse, I can't decide if this is freakin' hilarious or freakin' scarey!

Both, I guess.

I would love to hear "Nurses, it's time to tell EPIC it's OK." at our institution. Then pet the doctor who's trying to chart.

EMG said...

Yes, because we all know how well leaving bedsore prevention to individual initiative works.


These aren't nurses, for the most part, they're CNAs and LVNs. I can live with a PA reminding them to do their job if it means a few more grandmas manage to avoid getting their flesh eaten away down to the bone.

But patients' experience is a lower priority than some Norman Rockwell myth about professional independence.