Health Care

Hospital in a hospital delivers model care

For Mark Elsworth, the road to recovery may last years.

Last May, the 56-year-old mechanic and bus driver for Derby schools had just recovered from pneumonia when he noticed weakness in his arms. Within days of the onset of symptoms, he had to be put on a ventilator.

He underwent five plasma exchanges and at one point, his heart stopped.

Elsworth has Guillain-Barre syndrome, an autoimmune disorder in which the immune system mistakenly attacks the nervous system, causing muscle weakness and even paralysis. In Elsworth’s case, he was paralyzed from the eyes down and couldn’t speak for several months.

“I couldn’t express what I wanted to say,” Mark Elsworth said. “Trying to explain to somebody with just your eyes …”

“It drives you crazy,” his wife, Anne, finished.

After starting at Wesley Medical Center, he was referred to Select Specialty Hospital, a “hospital within a hospital,” located inside Via Christi Hospital on St. Francis.

He stayed at Select Specialty from June 15 to Oct. 23.

“For the most part, they did a fantastic job,” Mark Elsworth said.

He was able to get off of breathing assistance in October.

“That was a huge deal for us,” Anne Elsworth said. “They say his was a very severe case.”

After leaving Select, Elsworth spent two weeks in Wesley Rehabilitation Hospital before going home.

Anne Elsworth says they were lucky they had good insurance and that family and friends help take care of Mark so that she can continue to work at the Kansas Turnpike Authority.

Now, he undergoes physical therapy, has a tracheotomy and has gained back some movement in his legs, feet and fingers.

‘A different model’

Select Specialty Hospitals work with 2 to 3 percent of the sickest patients, said Peggy Cliffe, CEO for Select Specialty Hospital in Wichita.

“Most patients are coming from an ICU and we’re very similar to a step-down ICU,” Cliffe said.

The hospital, called a Long Term Acute Care facility, works with adult patients who typically have complex respiratory issues and may be on a ventilator, patients with complex wounds and patients who may have had complications after surgery.

The Wichita hospital has an 80 percent ventilator wean rate, Cliffe said.

There are more than 100 Select Specialty Hospitals in the U.S., Cliffe said, and most are inside other hospitals.

The company likes that model for several reasons, she said.

“The primary reason is that the majority of our staff are direct patient caregivers and it allows us to focus on providing patient care. We still have all the other services to operate as a hospital,” Cliffe said.

Select has its own nurses, respiratory therapists, pharmacy and case managers, among other staff. But other services, such as lab work, upkeep of the facility and housekeeping are contracted out.

It does not employ any physicians but gives doctors privileges to work in the facility. It employs roughly 150 clinical and administrative staff.

Select is a for-profit, publicly traded company that receives patients based on referrals from other hospitals and physician offices.

In 1999, the Wichita Select Specialty Hospital opened at Wesley Medical Center with 30 beds. It added 30 beds at Via Christi Hospital on St. Francis in 2004 and closed its Wesley location completely in 2007, Cliffe said.

Now, it has 60 beds at St. Francis on the fifth and sixth floors.

Select staff see about 500 patients a year, Cliffe said. Most patients are older than 65 and Medicare-eligible.

Elsworth’s length of stay – several months – was unusual for Select.

The Wichita hospital’s average length of stay is 28 days, Cliffe said, and in order to meet Medicare reimbursement requirements, patients have to have an average stay of at least 25 days.

About 35 percent of patients go home after their stay, about 35 percent go to a skilled (nursing) facility, and the rest typically go to rehabilitation facilities, hospice or other care facilities, or they die.

Cliffe said that Kansas Medicaid does not recognize long-term acute care for reimbursement purposes.

The cost for patients who stay in LTAC hospitals can be more than a typical hospital stay, Cliffe said, due in part to lengthier stays and more intensive care.

However, she said a stay in an intensive care unit is typically more expensive than at an LTAC hospital.

“In a post-acute arena, like rehab hospitals, skilled nursing and long term care facilities, we’re certainly more costly because patients are sicker and in the hospital for a longer period of time,” Cliffe said.

The rate per day would vary because of services the patient would need, Cliffe said.

“Some have a high level of intensity when they first come in and over the long haul, those come down,” she said.

By January 2014, all Select Specialty Hospitals hope to transition to a full registered nurse staff, Cliffe said.

“The LPNs we have are in a transition program and going to school. If they chose that path, Select is helping them with that,” Cliffe said. “That was a company-wide decision because of the complexity of care for our patients. We felt that we really needed the RN-level of expertise.”

Chief Nursing Officer Lindsey Cahoj said the clinical staff works as a team to assess patient progress.“We have weekly interdisciplinary team meetings where all the specialties in the clinical staff get together and we round on every patient in the unit to tell where they are in their plan of care,” Cahoj said. “We do it at their bedside so the patient and the patient’s family are involved.”

The hospital is accredited with the Joint Commission and expects its next review in April.

It is not on Medicare’s Hospital Compare website because long term acute care hospitals have not had to do mandatory reporting on quality control measures, Cliffe said.

Under the Affordable Care Act, those facilities will have to report at least three items: bloodstream infection rates, catheter associated urinary tract infection rates and hospital acquired pressure wounds.

That data will likely not be available until later this year, Cliffe said.

Requesting regulation

Select Specialty Hospitals has asked Congress for more guidance on the types of patients Long Term Acute Care hospitals should serve.

Sen. Pat Roberts sponsored the Long Term Care Hospital Improvement Act of 2011, but it died in committee.

A representative from Roberts’ office said he is considering reintroducing the bill this legislative session.

“In a nutshell, doctors and case managers at the large, general hospitals need very specific information on when it is appropriate to transfer a critically ill patient to a long-term acute care setting,” said Ed Bodensiek, vice president of public relations and communications for Select Medical, in an e-mail.

“This is currently done via clinical liaisons working closely with the patient’s doctor and treatment team in the ICU, but it varies by state, by city, and indeed by hospital. This makes it hard to create national standards and benchmarking, among other challenges.”

“Really the only criteria Medicare has for us to maintain our specialty is a 25-day length of stay,” Cliffe said. “In order to be judicious and prudent to make sure we’re taking the right kinds of patients, we absolutely want a bill that would mandate admission criteria across the board. That would level the playing field for all the LTACs in the industry, that they would have to follow a set of criteria.”