16 - Transitional Care (Dr. Clete Younger)

Dr. Clete Younger joins Dr. Arnold to talk about the new Transitional Care Center and how it helps patients with the transition from hospital to home.

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Transcript

Dr. Arnold: 
This is LiveWell Talk On…Transitional Care. I'm Dr. Dustin Arnold, Chief Medical Officer at UnityPoint Health – St. Luke's Hospital. Everyone hopes to go straight home from the hospital after illness or surgery, but that's not always the case. For some, recovering from a major surgery or a serious illness going straight home after that is just not feasible due to lack of strength and other medical conditions they may have acquired. St. Luke's Transitional Care Center Medical Director, Dr. Clete Younger joins us to tell us more about this specialized facility and the services which it provides. Thank you for coming. 

Dr. Younger:
Thank you. So, my name is Clete Younger. I am a family physician here, practicing in Cedar Rapids. I'm also the director for the Transitional Care Center as well as our Post-Acute Program in the Cedar Rapids region. I also serve as the Hospice Medical Director. So, today I'm going to talk about our new model of care that we're presenting, which is a Transitional Care Center. So, to understand why this is new and different, first, you have to understand what we currently do or what the current state is. So, there's a lot of pressures now for patients to get into the hospital, get well quickly, and get from the hospital to the next level of care as fast as possible. A lot of times there's insurance pressures for that or safety issues with regards to not getting other infections while in the hospital, but unfortunately that pressure to move through the hospital quickly doesn't get people all the way healthy and ready to return home. In that scenario, if patients aren't ready to return to their home environment, then they go to something called skilled rehab where they can receive skilled nursing. The current model is, as it exists in Iowa, is that skilled nursing typically exists within a nursing home, so there'll be a section of a nursing home that is incorporated or separate from the patients that are there for long-term care where a patient will go after they leave the hospital but direct from the hospital where they will then receive rehab and nursing care in that nursing home setting. They'll be there for a period of two to four weeks, get stronger, have their medical conditions managed, and then return home.

Dr. Arnold:
Now, some of the rural hospitals, have what's called swing beds, where they can actually do that inside their hospital. St. Luke's is too big, we don't qualify.

Dr. Younger:
So, the challenge with that is that patients still have to go to a nursing home in order to receive that care. So, that means you have a population of patients that are there for long-term care and a subset of patients that are, they're receiving skilled rehab. So, you have two different populations of patients existing within the same environment. There's challenges with that. Some of the challenges are we're not in that sort of environment specializing our care to just our skilled rehab patients. We're kind of diverting our care between the two different groups. It's also pretty intimidating for a patient who has just had a hip surgery or had a heart surgery or had an infection who's never been in a nursing home setting to then go to a nursing home. That can be a very hard transition for the family to make and for the patient to make. And sometimes we see a lot of resistance from patients to do that. So, they don't receive the adequate skilled nursing that they should because they just don't want to go to it.

Dr. Arnold:
There certainly is a stigma about going to a nursing home for elderly that this is the end. You know, sometimes you'll hear, and I know you've probably heard this Clete, you know where someone passes away. Well, but she was able to stay in her home until she passed away. You know, like that's some sort of merit badge. But that’s not the case. Nursing homes aren't like that, are they?

Dr. Younger:
No, but it's, it's tough to get past that. Or the term that I hear often is that if I go there, I'm never going to leave. And so, you know, when that is the patient perception, that's really hard to then get them to be compliant with the nursing and therapy when that’s kind of the initial a feeling going there. Now we actually, in Cedar Rapids, provide excellent skilled rehab in nursing home settings. So, in our organization and across the state, we actually perform extremely well with the patients that we take care of, particularly the patients that we follow with our UnityPoint Post-Acute Team. We follow patients in nine different nursing facilities in the Cedar Rapids area.

Dr. Arnold:
Why don't you talk about your Unity Point Post-Acute Team. Walk me through that structure and its relationship to the inpatient physicians that practice in the hospital and those that practice in the clinic.

Dr. Younger:
So, there's the opportunity for patients to have our team follow it. And when I say our team, it's me as a medical director for that program, as well as the group of four nurse practitioners. So, what we have done is basically take on the role of the person taking care of the patient during their skilled rehab stay. So, the old model of that was a patient would go to a skilled setting or a nursing home setting and then they would have to go out to see their primary care provider or just no one would ever come for a couple of weeks and they would do rehab and go home. The problem with that is it's hard to leave skilled rehab to go see a provider and your time with providers fairly limited, or if no one ever came to see them, there's an opportunity that things could happen, or things could go wrong before a provider could be involved. So, we actually have a team where we're dedicated to doing that. So, I work with a group of nurse practitioners. Our time is dedicated to do those things. We go see patients in the facility where they're at. So, by doing that we can provide the service to them where they're located at receiving their skilled nursing, but we also have lots of access. So if a patient is getting sick or if a nurse calls us from a facility saying, “Hey, this patient isn't doing well” or “pain's not controlled” or “we're worried about an illness,” we can react to that by having a nurse practitioner come physically see them where they're at and intervene. We've been really successful at that. In that we have lowered our risk of rehospitalization, so patients come back to the hospital less and we've been able to accelerate their time through therapy. So, instead of staying in a nursing facility setting for four to five weeks, we're averaging more like two to three weeks. So, we've almost cut in half the amount of time patients have to be in skilled rehab before they return home.

Dr. Arnold:
That's a great, I mean, and even if they do get readmitted, I've found that it's more of a strategic readmission because they come back for a single purpose and they use less resources rather than just being sent to the ER after hours.

Dr. Younger:
Yeah. We really try to own that skill when they come to our care and our Post-Acute Team, we are very vested in that patient's outcome. We want them to have a good outcome. We want them to get back to their home setting. We don't want bad things to happen. And we take that on very personally. And I am very fortunate that I work with a group of nurse practitioners who are not only very clinically skilled, but they are very passionate about their work. They're all geriatric nurse practitioners. So, their training background includes being a nurse and all three of the ones that we work with here in Cedar Rapids were ICU nurses before they got their nurse practitioner degree. So, they have really good clinical experience. But that's combined with now the clinical experience they've developed as a geriatric nurse practitioner caring for our patients in the post-acute setting.

Dr. Arnold:
You know what, in probably 2006 that was my idea to put a nurse practitioner at ManorCare and was, you might remember, Julie Shaw and that was, people looked at me like I was crazy and I had to shop around at nursing homes and it was ManorCare. I went to all of them and they just that no that's not something we think we'd be interested in. But it's been proven to be a model that works and works well.

Dr. Younger:
Yeah. I think finding the ways to extend physician care by using physician assistants or nurse practitioners has been a very good model. So, you can take what one physician can do, ‘cause we have a physician shortage in Iowa, we just don't have enough physicians for everything. Nurse practitioners and physician assistants can help fill that role to really extend those physicians services. And I really enjoy the fact that nurse practitioners bring a really unique background cause they were nurses before so they really know a lot about the nursing details plus their clinical knowledge and they can provide thoughts and ideas and treatments that, you know, sometimes I don't even think of the physician cause I haven't had that issue.

Dr. Arnold:
Right. Absolutely. That's, that's a great point. Tell me about the new facility. What's its capacity?

Dr. Younger:
So, the difference with this current facility is the transitional care center is all skilled rehab. So, there’s no long-term residents at all. Everybody that comes to that facility is there for a short period of time. Then they're transitioning to home or to a different environment. So, the entire building is focused around that transition from hospital setting back to a homelike environment. So, we are currently licensed for 48 beds. The facility is 46,000 square feet, and the entire structure of the building was based around our experience in post-acute care for the last several years with our team model, with nurse practitioners. We basically built the building to try to make that process work as efficiently as possible. So, everybody there is working towards that skilled rehab stay specifically. So, the nurses, the therapists, people that do cooking and cleaning, everybody knows that the patients are transitioning through that facility. So, there's a very positive vibe of we're all trying to get from this place where we were in the hospital back to a home setting,

Dr. Arnold: 
Really haven't had the data to show that it's influenced readmissions. I mean, I think going to happen, because it opened in September?

Dr. Younger: 
It opened August 28th. 

Dr. Arnold: 
August 28th. All right, well a month behind there. So physical therapy, occupational, speech, 

Dr. Younger:
Yes.

Dr. Arnold: 
All offered. 

Dr. Younger: 
All offered. We are very fortunate with a new facility. We have lots of space. So, space is a big deal. So, if you're sick or if you've had an orthopedic injury--

Dr. Arnold: 
It's also the final frontier. 

Dr. Younger:
Yes, so, space, having that space to move around and do it safely reduces falls. There's also the effect of reducing infections. So, we are very blessed with lots of space in our facility. We have an enormous therapy gym with multiple different available modalities and different things that patients can train on like curbs and doorways and stairs so that they can practice things that they're going to need to do before they go home. But it also gives them lots of space. So, we have more privacy for patients. We have lots of space for patients to work. We have lots of spaces for the therapists and the nurses to work around them. And it just makes the whole experience safer and you just don't feel as crowded and rushed. When you're in a new setting. We also have lots of windows. So, your experience with the environment is also much better cause you can see natural light, people can experience a normal day and nighttime sequence and that really helps patients get better.

Dr. Arnold: 
So, if I'm a patient, I'm going to have surgery and I have medical conditions and I know that I'm not going to go from hospital to home when they need that transition, can I visit ahead of time? If there is space, you know, have space available and say, this is where I want to come and see it before I have that surgery. 

Dr. Younger:
Yes. So, we decided that the facility to just offer that on an as needed basis. So, if patients either call the facility or if patients arrive at the facility and want to get a tour of the facility, we are providing access to that. And that usually is provided either by our directors of nursing, our nursing staff, our therapists, or even our administrator who used to be a physical therapist. So, she's very passionate about the work that we do there. So, and that's what we've done since the building's open. When people want to see it or want to take a look to see if that would be the right place for them, we're providing that service on an as needed basis.

Dr. Arnold:
What percentage, and you can just guesstimate this, Dr. Younger, what percentage is recovering from an elective surgery? What percentage is recovering from a medical condition that perhaps hospitalized him?

Dr. Younger:
So, recovering from an orthopedic condition is actually pretty rare now. So, we've gotten so good at the preparative planning for surgery. We optimize patient's diabetes, chronic medical conditions, and set them up so well for surgery that almost all patients go home from an orthopedic surgery. Now, when people have traumatic events, that's different. So, we do see a significant amount of hip fractures, pelvis fractures, humerus fractures, so an unplanned orthopedic surgery. We take care of that quite a bit. But a planned orthopedic surgery is actually pretty rare. And that's a testament to our orthopedic group, our anesthesia group, our preparative surgery group. They're really working hard to get people from surgery to home, which is an excellent situation for those patients.

Dr. Arnold:
We have a podcast with Nassif and he has hit the 200th total joint that he's done at the surgery center. So, those people were going home that day. That's impressive. I mean that is impressive.

Dr. Younger:
And it's a lot of work on the front end but it's much better for the patients, less illness, less complications. They do extremely well. It's the unplanned things that are tough. Unplanned things including falls with fractures and we really are now seeing a lot of patients with complex medical conditions together. So, what we really work hard in and what we probably specialize in the best is managing multiple medical conditions together. So, this is heart failure, diabetes plus complications with orthopedic joints, arthritis and cognitive problems. Cause when you combine all of those different things together, the way you take care of a patient gets complex very quick and you need somebody to look at the patient's case. From a general view, having involvement of our specialists is extremely important and we have very tight connections with our specialists and we reach out to our cardiologist, kidney doctors, endocrinologists often when we have specific questions. But what we really do is provide the overview of care of, we're looking at every medical condition, every single medication. We're looking at how they interact with each other and really trying to make a plan for how we're going to manage it.

Dr. Arnold:
And you're, you're sharing the medical record. I mean, it's open access on that standpoint, which is so important for continuity. Are you worried about mission creep or are you worried about perhaps maybe a higher acuity slipping into the facility? You know, trying to keep the hospitalization short but still treating the patient?

Dr. Younger:
Yes. So, the trend is to push everything to the next and less expensive level of care. So, it went from patients that used to be in the ICU are now managed on the floor. Floor patients we're now trying to push into skilled rehab, skilled rehab patients that were traditional skilled rehab like when I started, are now usually taken care of in the home setting. And the reality is, you know, we can’t afford our healthcare in the United States. We have to do a better job of controlling costs. We have to do a better job of getting people healthy without overextending our resources. So, it's not surprising that we're seeing these transitions in levels of care and where we're trying to take care of patients because we just need to find a more affordable model. What we're doing right now in the U.S. just isn't sustainable.

Dr. Arnold:
Yeah. And that's it. The pie's not going to get any bigger and we're going to have to do more with less. I mean, that is just a bare bone truth. Why did, what got you interested in this, post-acute care?

Dr. Younger:
So, I was very fortunate during my training that my mentor was a geriatrician, so I spent a lot of time with him, particularly taking care of geriatric patients and then palliative care patients as well. I was drawn to the complexity of care. So, it's fun if you like healthcare to really take on that complexity of care and then try to optimize it the best that you can. People really appreciate that too. Particularly if you can take a patient who is very sick or very ill and get them to a better place, you can really see that their families really appreciate that. I'm also drawn to it because I'm inherently a minimalist when it comes to healthcare too. So, instead of adding more, doing more, there's a lot of things we can actually do by doing less. So, there's a lot of issues that we run into with too much medicine or too many healthcare interventions actually making patients worse. So, I have been really passionate. I was fortunate in my training to be trained how to really minimize things to actually make patients better. And it's really remarkable sometimes to see a patient who actually gets better if you do less. And that's very rare.

Dr. Arnold:
Absolutely. Absolutely. Absolutely. Yeah, I personally feel it’s a merit badge to stop a medication. Anybody can start a medication, but if you can see a patient, if there's a way to get them off that medication, that’s something you can be proud of at the end of the day. 

Dr. Younger:
And we really take that on. So, besides getting people better, I mean, when somebody goes in the hospital for acute condition, we want to take them to the transitional care center and get them past that episode. But we actually often talk to patients about, you know, maybe we can make you better than before you were hospitalized. Like that's not an unreasonable goal. So, we sit down with patients and talk about what are these medications actually used for? Who has seen this? Who has managed this? Can we actually optimize your care better? So, when you leave the transitional care center, you're actually healthier than before you were hospitalized. And it's not uncommon that we get people through that process and they actually come out of that facility better off than before they were hospitalized.

Dr. Arnold: 
That's outstanding. Well, this is really great information. Thanks for taking the time to talk about this. I think this is a very, very interesting topic and I think we'll bring it back and talk about the results maybe in about six months and brag a little bit about how well you've done. Again, this is Dr. Clete, Younger Medical Director of St. Luke's Transitional Care Center. For more information, visit unitypoint.org if you have a topic you'd like to suggest for our LiveWell Talk On… podcast, shoot us an email at stlukescr@unitypoint.org and we encourage you to tell your family, friends, neighbors about our podcasts. Until next time, be well.