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."