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Ep. 137 - LiveWell Talk On...Skilled Nursing (Dr. Clete Younger)

episode 137

Ep. 137 - LiveWell Talk On...Skilled Nursing

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Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guest: Dr. Clete Younger, medical director, St. Luke's Living Center

Dr. Arnold:
This is LiveWell Talk On...Skilled Nursing. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's, Cedar Rapids. As a practicing physician for now 25 years, I can honestly say some of the toughest conversations to have with individuals are: one, to stop driving. And two, discussion of placement in a nursing home. Both of them revolve around loss of independence. So to talk today, back to the podcast is Dr. Clete Younger, who is a medical director for St. Luke's Living Center. We only have one now, that's right. He has extensive experience and is quite knowledgeable in skilled nursing facilities and their capabilities and their functions. So we're having him back to the podcast to discussed that. Welcome back, Clete.

Dr. Younger:
Thank you very much. Good to see you.

Dr. Arnold:
You know, I'm sincere when I say that. I think that's a tough conversation to have with people, don't drive and you can't live at home anymore. Everything else is kind of an easy conversation.

Dr. Younger:
Yeah. Both those things are freedom and independence, and when you take those away, people know they're losing their freedom.

Dr. Arnold:
Yeah. People are kind of taken back when you say, not that I want to tell a patient that they have cancer, but that's an easier conversation than to take away their independence. Could you just give us an overall, what is skilled nursing? Put some bookends on it. What is skilled nursing? What does it do? What doesn't it do?

Dr. Younger:
We have different levels of care. So, you know, people are familiar with maybe assisted living or senior living, and that can have a lot of variability. That can include nurses, not have nurses, have meals, not have meals, have medication set up, not have medication set up. The two levels of care, which are higher levels of care, are intermediate care, which is long-term nursing care, like what people would think of as a traditional nursing home, or skilled nursing services. Skilled nursing services are typically a defined period of time for recovering from a specific medical condition. So that could be 12 days. It could be sometimes a couple months, but that's by definition a period of time, whereas long-term or intermediate care is considered a very long-term or long-term nursing home care.

Dr. Arnold:
You know, we talk about transitional care, transitions of care, and transitional care. How does that fit into the spectrum of this post-acute or post-hospitalization healthcare?

Dr. Younger:
So what we hope is that somebody will have a transition of care where they have, you know, a knee replacement or a hip replacement, and they need rehab to get back home. Or they have a pneumonia, they're hospitalized, an infection of some sort, and they go through a hospitalization, which now we try to keep quite brief. You know, even a couple of days, so we can get people moving on to the next level of care. That next level of care, then, if somebody needs extra, help would be a skilled nursing stay. And during that period of time, people continue to receive medical care. But really the goal is to work on rehab. So occupational therapy, physical therapy, speech therapy, and the goal is to rehab them from that acute illness from the hospital, to something else. Now the challenge becomes, is what is that something else afterwards? Are we getting people back to their home setting, or is that hospital event kind of a marker of dysfunction, that now even with a skilled stay, now we've identified somebody who is a danger in a home setting, or they have a medical problem that we didn't realize it's unstable. Then now they're going to need to transition from a skilled nursing stay, to assisted living, or they're going to have to move in with a family member. Or in some cases, are going to have to move to a nursing home long-term.

Dr. Arnold:
Okay. What percentage—and this might not even really be a fair question, but I'm curious—what percentage of patients that go into it with the anticipation of getting enough skill to return to their home, actually return to their home?

Dr. Younger:
I would say greater than 75%.

Dr. Arnold:
Return home?

Dr. Younger:
Return to their previous home, like if they were in assisted living before, they go back.

Dr. Arnold:
Their previous level of care.

Dr. Younger:
Yeah.

Dr. Arnold:
Okay. And what's the average, or usual duration that somebody participates with skilled care?

Dr. Younger:
So at the transitional care center, we kind of have the best length of stay. When we say best length of stay, it's the shortest. We get people back home the fastest. Our length of stay hovers around 12 to 14 days. Statewide average is somewhere around 24. So that's kind of a typical skilled stay. At the TCC, we're able to get people moving a little bit quicker just because of the model of care that we have there.

Dr. Arnold:
Okay. So a couple of weeks.

Dr. Younger:
Yeah. We usually we tell people a couple of weeks, because people can understand that, kind of in those terms.

Dr. Arnold:
I use this format. I think you might've had this conversation, that for every day you're sick in the hospital, it takes about three days to get your strength back.

Dr. Younger:
That would be fair, yeah.

Dr. Arnold:
If you're here five days, it's going to take two weeks before you're going to feel back to baseline.

Dr. Younger:
Yeah.

Dr. Arnold:
That was a small British study done in the early 90s, where people that had community acquired pneumonia, they gave them these postcards and they were to mail it in every day until they felt that they were back to the baseline, and then they were to stop.

Dr. Younger:
That's interesting.

Dr. Arnold:
And it came out to three days. And so that's held true over time. Now, could you talk a little bit about your team you have. ARNPs, nurse practitioners, that work with you out in these skilled care facilities. You know, when I ran the hospital's program and we started and got a nurse practitioner over at ManorCare in 2005, I think. That was, kind of, nobody else was doing that. You know, now it's commonplace and you have a well-trained team. Tell me a little bit about your team.

Dr. Younger:
Yeah. So there's actually a term that's called a SNFS, which is an S-N-F-S. So basically, they specialize in doing skilled nursing care. And so that exists across quite a few areas across the country, particularly in larger cities. We don't see that in rural settings, like in Iowa. So you're only going to see that really exist in places like Cedar Rapids, Iowa City, Des Moines. But our team consists of me and three nurse practitioners. The three nurse practitioners I work with, they're full-time skilled nursing care. They're salaried employees, which is awesome because they get can spend as much time as they need to with anybody, without having any quota that they have to meet. If they need to talk to a family for an hour and a half to get them to where they need to be, they can spend that time with them. They can really dictate the time that they need.

We also, we follow patients at 11 different facilities throughout the Cedar Rapids Metro. So any given day's a little bit different for us. We're traveling around quite a bit, dictating our day based on the needs and the individual situations or acute things that come up with patients. But what we really try to do is be available to the facilities. What we found is that if you identify a problem early and you're able to go, you know, lay eyes, physically see somebody, you can stop a problem early. So somebody doesn't get re-hospitalized. As soon as somebody goes back to the hospital, we're basically starting the clock over on their skilled stay. So we really want to keep people out of the hospital. So what we try to do is be present, be available to our nurses, and we really try to empower our nursing staff that we work with to call us if they're concerned. I want a nurse to feel comfortable calling me. You know, if it's the middle of the night or middle of the day, if they feel like something's going wrong, I don't want them to be scared to call us. I want them to call us and say, hey, I've noticed this, let's talk about it and where we want to go. So we really try to create a culture with our nursing staff, where they feel comfortable contacting us if they feel like a patient is going in the wrong direction, so we can assess it and then work with them to find a solution to get them healthier.

Dr. Arnold:
Yeah, we discussed, and I know you've been involved in some of those conversations on the medical staff. We talk about a culture of approachability, where it's scholarship and inquiry. Everybody feels comfortable asking, this doesn't look right. You know, and are encouraged to do such, because that speak up culture really does, you know. One time out of 10, it's going to say someone's life quite honestly, you know.

Dr. Younger:
Yep. Yeah.

Dr. Arnold:
And that makes it worth it. Let's talk a little bit about the pandemic and COVID-19. How has that changed? First of all, I think your team, you individually, but your team as well, did a great job of discussing with families early on in end of life care and the complexities and the severity that COVID-19 has on older patients. And I said, two milestones in the pandemic for me were: one, your action in that, I think was so valuable. And the other was the vaccine. I mean, those are kind of the things that, okay, were game changers. And I'm really impressed with the work you did at that time. Kind of walk me through how that has changed nursing homes, if at all. As you know, I stop off at Hiawatha Care Facility and help with some wound care. People that can't get out of the nursing home, and it's on the way home and so I stop in and see them. You know, that's the only nursing home I went into during this time, and they work so hard to keep people safe and really manage the infected patient. So tell us a little bit about how you handled things. And does the nursing home look different than compared to the pandemic?

Dr. Younger:
Yeah, I mean, everybody got really scared to be in a nursing home. So even trying to get patients to go from the hospital into a skilled stay was really difficult because people were so terrified of, you know, what would happen. One, if they would get sick. And then two, you know, early in the pandemic, we had lots of visitor restrictions. So families couldn't even come even into the building. I mean, at Living Center West, it has two stories. We rented a scissor lift to take families up to a second floor, so that they could look in the window and see their loved one because they couldn't go in the building. I mean, there were really extreme things that were going on and we saw lots of weight loss, lots of depression, because people couldn't get out, they couldn't see their families. Fortunately, the visitor restriction part has become less. We can have some new guidelines. And really, the vaccine was an enormous difference as far as, you know, the risk profile that these facilities have.

So now what we see, unfortunately you can still have breakthrough cases. And so we've seen that, even despite vaccination. Partially because our vaccinations for nursing home residents was like seven months ago now. So we're really hoping for that booster to come, at least for our nursing home residents, but the severity of illness is completely different. Every single patient that I've taken care of, that's a geriatric patient or a nursing home patient that has had a breakthrough infection with COVID, has had mild disease and recovered. Whereas last year, 15% of them died. And you know, about half of them had severe illness that required lots of intervention. So the level of, you know, the disease burden for these patients now being vaccinated, is so much different than what we were dealing with between April and November of 2020.

So that is certainly a lot better. We actually, you know, we saw lots of weight loss and depressive symptoms, which we're now kind of rebounding from. So we've seen kind of a whole shift in our facilities of, we're using less antidepressants. We're seeing less weight loss. People are kind of gaining weight again. And that occurred, kind of starting, you know, in March and April of this year when things kind of started to open back up. And so it's been interesting. We've had multiple patients graduate from hospice, actually. You know, into 2020 to 2021, you know, they were failing, losing weight, and met hospice criteria. But then as things started to open up, more activities, communal dining with other residents, and their families, all of a sudden that spark was back and we were able to graduate some people from hospice. So it's a lot different than it used to be. There's still a lot of trepidation for people wanting to come into nursing facilities, just because they're still so fearful of what the pandemic is. And there's a lot of misinformation about all things pandemic, but that includes like visitor restrictions and, you know, some of the things that happened in nursing homes during kind of the peak time when it was really challenging.

Dr. Arnold:
And I think the nursing homes here in the Metro, all of them were pretty innovative in trying to meet the needs of their patients and trying to have business as usual, if you will, but still that contain the pandemic. Whereas, some other states they just shut down, you know. So for 18 months, these people haven't had visitors, which is, you know. I mean, solitary confinement is what they threatened people with in prison. You know, if you don't behave and follow the rules, you're going to get solitary confinement.

Dr. Younger:
Yeah. I mean, the other concept to think about is in the United States, the average lifespan of somebody who enters a nursing homes about 18 months. So one of the things that we were really struggling with was, so if it was, if you go back to March of 2020. If you're a nursing home resident, even though people don't necessarily know that statistic, they know that statistic. Human beings have instincts on that. They know when they go into a nursing home, that that's a limited lifespan at that point. And back in, you know, in 2020, we had everything shut down. So you can imagine how demoralizing it was for a resident to think, "I don't have that much longer to live, and this is the world that I'm living in, that's all locked up." That was really hard emotionally to see people going through that, because everything they were thinking was logical. And you know, a lot of people just gave up because they had no other choice.

Dr. Arnold:
Yeah, it was a dark time quite honestly. And we've learned a lot about ourselves. I say, we know what we do. We know how we do it. It's the why. And I think we all reaffirmed our "why" during this time. Just kind of take me through, let's say I had a hip fracture, independent living, I break my hip. It's repaired. I'm in the hospital three days, let's say, and then I go to the transitional care. What's my next couple of weeks look like? What's a day look like in a post hip fracture patient?

Dr. Younger:
So, at the TCC we have a schedule that we print for every patient for every day. And it will include the times when they're working with physical therapy and occupational therapy, as well as meals. And then we have care conferences with patients and families at least weekly. You know, we really try to assess where are we going back to. You know, what sort of setting are we going back into? If it's an assisted living or senior living, that's a place that's designed for somebody who has a mobility impairment to live there. Where we really, where it gets a lot more complex, are stairs. Homes that have odd, you know, stairs situations or odd situations to get in and out of the house. Bathrooms that are on separate floors, families that may or may not be nearby to check on them, or people that they live with.

So we quickly try to do an assessment of where are we going back to, because that dictates where we need to go. If you're going someplace where you have no stairs, we don't need to work with you on stairs. But if you have a split level home, oh boy, those stairs are becoming very important because that's the highest risk thing that you probably have going back home. So we really try to assess what that risk situation is. Is it medication management? Is it stairs? Is it some other functional thing, or family support? So setting goals early, so that we can prepare for what that patient's life is going to look like once they get out of there. And we really try to work towards, let's try to mimic what your situation is going to be at home as we get to the end of the skilled stay, so we feel more comfortable about sending you back into that situation. And I'll often say to patients: what are you worried about, about going home? You know, as we get close to the end of their state, what are you concerned about? Because my job is then to try to help you figure that out. And we need to work with our therapists to make that happen so we can get people home successfully.

Dr. Arnold:
So, I had my hip fracture. I know that I can't have stairs at home. I know I need some rehabilitation, right. What are three questions I should ask you about where I'm going? What would you like to see patients know?

Dr. Younger:
I would say, how much therapy am I expected to have during the day? Because I think people need to plan that, it's like planning exercise. You need to know, what level of commitment do I have to make every day? With the understanding that the more motivated you are to work with that therapy, the faster we'll get through it. I would ask about what is your schedule during the day? You know, some people sleep in, you know, sometimes the way the building schedules are designed don't necessarily match up with people's sleep schedule. So even though we can't always match up with somebody who's a night owl, that doesn't always work with therapy. If the patient knows that going into it, they at least can mentally prepare for it before they get there that first day and realize that, oh, I might have a therapy session at seven and I usually sleep till 11. You know, if they have like a prep for that a little bit, it makes it a little bit easier to accept that. And then I think, what are my goals to leave? And that's something I talk to often with patients. These are the things we have to achieve in order for you to get past this point. Because if you don't know what your goals are, you're not going to feel comfortable working with therapy on a day-to-day basis.

So in our case conference, and during our physician rounds, we talk about, these are the things that we have identified that we need to fix in order to get you back to the setting you were at before. Some of it's physical, like going upstairs, or being able to take a shower, or getting in and out of a wheelchair, but some of it's medical too. You know, we need to stabilize this medical problem and have a good plan for it and have somebody in charge of it at discharge, so that we can continue this medical problem monitoring and management, to make sure that it's safe at the time of discharge.

So, what are my goals? What are my expectations? As far as like the timing of my therapies and interventions, are very important.

Dr. Arnold:
Well, this is great information Clete. Once again, this is Dr. Clete Younger joining me today, coming back to the podcast. How many podcasts have you done?

Dr. Younger:
I think this is the third or fourth.

Dr. Arnold:
I want to say it's fourth.

Dr. Younger:
Yeah, maybe the fourth. 2020 was so long, that it's hard to remember everything. And everything feels like forever.

Dr. Arnold:
Isn't that true. And especially kind of with this Delta surge. It's just like, okay, didn't I already do this?

Dr. Younger:
Yeah. I guess there's one other thing. Dustin, do you have time for me to talk about one more thing?

Dr. Arnold:
Yeah, of course.

Dr. Younger:
So, you know, there's another thing that happens when we talk about this transitions of care. And we see this a lot in our skilled setting, but also in our clinics. And what happens, is unfortunately there's a natural trajectory where everybody loses function as they get older, either due to age or due to a medical problem. And what we see is really, there's one of two things that can happen as people progress through aging. If they get to the point where their functional ability is not consistent with their home situation, where they're living, there's really two things that can happen. We can identify that and tell patients that, hey, this is probably the time you need to think about a higher level of care. And it's a time when you're doing it in a controlled situation. You can look at assisted livings, or senior livings and nursing homes, make a good choice and figuring out where you can go.

The other situation is what, unfortunately, we see happen quite often, is a catastrophic event. Somebody falls and breaks something. Somebody has a really unstable medical problem or infection, that all of a sudden takes a significant amount of function away from them. And all of a sudden, it's right there in your face. You can't go home. And so what I try to talk to patients about is, I want them to be thinking about what is my next stage in life going to be? In, you know, six months or 18 months or three years, I might not be able to live at home anymore unless I have somebody who can provide 24 hour care.

If that's not the case, I need to start looking at assisted living, start looking at senior livings, so I can make a plan for when I start to feel like I'm failing, or a doctor tells me, hey, it's time to not be at home. They can make that transition without having the catastrophic event first. Because so often in the United States, you have to get really sick, then get a little bit better, to make it to your next level of care. And that's really not—I mean, from a geriatric standpoint, we hate that. I would rather somebody be like, oh, it's time for me to go to assisted living. Versus, they fall, break their hip, get pneumonia, have to go through skilled rehab for a month. And then it's like, guess what? You can't go home. And now, we have to make a decision on a very short time frame about a place that you're going to go live next. So we're really trying to avoid that catastrophic event and being honest with people about, it's time to look at a higher level of care and let's do it in a controlled setting before you have this terrible thing happen.

Dr. Arnold:
You know, you bring up a great observation. And I've always said that the patients that don't handle that well, are the ones that are very, very active into their seventies, you know. And, I mean, they're still bailing hay at 72. Then they break their hip at 73, and it's devastating for them. Where, you know, I would say the couch potato at 50, when they turn 72, they're like I'm doing everything I did when I was 50. Yeah. You're watching TV, sitting around, you know? And so they con they handle it a little bit better, but you're absolutely right. That is, particularly—and I'm going to be a little biased Midwest in the work ethic and people enjoy that. It's who they are; it's their dignity. And then all of a sudden, you're right. If they don't think about it, then you're not making that decision on your terms. You're making on whatever the catastrophe was.

Such wisdom from a young doctor. I like to see that.

Dr. Younger:
Thank you.

Dr. Arnold:
Because I'm going to be old someday, or older. So this is Dr. Clete Younger, he's the medical director and family physician with St. Luke's Living Center and family practice in the medical corridor. For more information on skilled nursing services provided at UnityPoint Health - Cedar Rapids, call 319-366-8714. Thank you for listening to LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcasts. We're available on Apple Podcast, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.