VA Program Redesigning Concept of Caring for the Elderly

A program at the Sepulveda Veterans Administration Medical Center is redesigning the concept of nursing-home health care and changing a lot of attitudes about treating the elderly along the way.

It all started three years ago when Dr. Stanley Korenman, chief of medical services at the medical center, and a team of associates decided to change their entire approach to nursing-home care.

In March, 1984, they began converting their 200-bed nursing home into an academic nursing home, emphasizing the use of medical residents.

The biggest change in the center’s treatment of the elderly, according to Korenman, has been using nurse practitioners to provide routine medical care for the patients and using residents specializing in internal medicine as the nursing home’s primary physicians.

Getting Better Care

As a result of these changes, nursing home patients are receiving much better care. “Patients are progressing faster and better,” said Sally Martin, associate chief of geriatric nursing services.

Even more impressive are the statistics. According to Korenman, “Transfers to the acute-care hospital are down 80%.”

“We are also returning patients to the community who we would never have thought possible only a few years ago,” said Dr. John Morley, who oversees the Academic Nursing Home program as director of the facility’s Geriatric Research, Education and Clinical Center.

It’s the only program of its kind in the nation, but a steady procession of medical educators and administrators from across the country suggests that it won’t be unique for long.

“You have to understand,” said Morley, “that the worst place to try and improve attitudes toward the elderly is in a nursing home.”

Success Is ‘Surprising’

“If every resident could be the private physician of George Burns or Bob Hope, they would see geriatrics as the most fun in the world.

“However, if, instead, you have patients who are somewhat demented, who spit at you when you come into the room, then kick you and wheeze in your face--it’s really surprising this program has been as successful as it has been.”

Traditionally, Korenman said, “it’s been very difficult to get new doctors, medical students and house staff interested in the care of people who are chronically institutionalized. This has always been a backwater of medicine.”

Under the program, each resident at the hospital is responsible for six or seven patients. “This gives them long-range experience with long-term patients,” Morley said. “In the process, they learn a lot about geriatric medicine.”

Morley considers the program’s geriatric nurse practitioners a crucial element of the program’s success.

To assist the nurse practitioners, cards have been created that outline specific steps for handling particular medical problems.

“Nurse practitioners cannot practice medicine,” said Martin, who is a trained nurse practitioner, “but they can follow standard procedures: draw blood, get appropriate tests done and assemble all the information necessary for a diagnosis.

“The physician may then be called and a decision made rapidly.”

Indeed, she stressed that all of this can generally be accomplished in less time than it used to take just to get a physician to see a patient.

“I think one of the most exciting things we have learned is that small things can make a huge difference,” Morley said.

As examples, he cited the use of air mattresses to prevent bedsores in bedridden patients and training such patients, whenever possible, to use a walker.

“Maybe all they can do is walk to the toilet,” he said, “but that means they no longer would need a catheter or an external drainage system and that means no urinary tract infection every two to three months.”

Another detail that can make a difference is good nutrition. “The problem,” Korenman said, “is not a lack of food but just getting their food off of their tray and into their mouth.”

Patients are carefully monitored and, when they are identified as problem eaters, a staff member assists them at mealtime.

‘This Is Very Simple’

“This is very simple,” Korenman said, “but it’s high-priority since, if the patients are not well-nourished, there will be a deterioration of their health.”

Little things may mean a lot, but there is still a place for major medical intervention. The initial patient workup is a good example.

“When we first started,” Martin said, “we found many patients with problems that had never been noted or diagnosed.”

Today, most patients are first seen in the main hospital’s geriatric evaluation unit. There, a team of specialists carefully examines each patient, often taking four or more weeks to finish the evaluation.

Such a complete workup has been shown to prevent later medical problems and limit future admissions to the acute-care facility.

“There is a certain percentage of people in every nursing home who wouldn’t be there,” Morley said, “and it’s fairly easy, if properly diagnosed, to make a big difference in these people’s lives.”

Improvements Stunning

Martin said the improvements she has seen as a result of the program have been stunning. “Prior to the academic nursing home, our turnover rate was very low,” she said. “One of the lowest in the entire VA system, in fact.”

“At that time, it was understood that when a (resident) came here they would stay here,” she said.

Now, Dr. Korenman believes admission to the nursing home is much less a one-way ticket. “With our new patients, we are doubling our turnover rate. That is, we’re helping patients return to the community,” he said.

Korenman noted that the program is drawing interest from teaching facilities across the country. “Since this is the only program of its kind in the nation, we get four or five visitors a week who want to learn about our geriatric program. And we think of ourselves as a model for our entire (V.A.) system,” he said.

Besides improving patient care and satisfaction, the academic nursing home program has dramatically improved staff morale. “It used to be that physicians resented coming here,” Martin said. “They referred . . . to our patients as ‘gomers,’ meaning they weren’t going anywhere.

“The staff here felt the brunt of that attitude,” she continued, “and became convinced that this had to be the worst place to work.”

Feeling Changed

However, that feeling quickly changed. “We decided to start the program on one 60-bed ward where morale was lowest and the amount of sick leave taken by the staff was unbelievable.”

“The month we began talking about the academic nursing home program and discussing the staff’s new roles, the amount of unplanned leave came down,” Martin said. “Then the month we started the program, it came down dramatically and it has stayed down.”

The physicians’ attitudes, however, were a little harder to change.

“When we started, the residents were ready to lynch the faculty,” Morley said with a laugh. Empathizing with his residents, he explained: “It is certainly extra work and extra work is rarely openly embraced by anyone, particularly in an area which was very unpopular to begin with.”

Thus, Morley admitted, the first year was “a total disaster.” He recalled: “During that first year, probably only 20% of residents saw their patients on any kind of an acceptable basis.”

Today, he estimates, the figures are reversed, with 80% of the residents seeing their patients regularly.

“We’ve seen a big change in physician attitudes,” Martin said. “They speak very highly of the nurse practitioners and the general quality of care over here.”

Have the physicians’ attitudes toward their patients changed?

Pausing a moment, Martin said: “Not as much as we had hoped, but they have certainly come a long ways.”

Martin added: “Historically, doctors have not liked caring for older, chronically ill patients. A doctor can’t just walk in, do his little treatment and watch the patient get well. The acute situation may respond to treatment but the patient is still ill.”

Such patients, according to Morley, can be traumatic for physicians. But in the academic nursing home environment, “residents learn how to cope with these patients and how to handle them with relative ease once they get into the real world.”