Ventilator Units in Nursing Homes: Be Careful What You Ask For.

If you yield to temptation, then beware of the devil.

Now that PDPM (patient driven payment model) is in place as a new reimbursement model for nursing homes, it is natural to explore opportunities to increase overall reimbursement. One such possibility is to accept more complex patients.

Since patients dependent on artificial life support (i.e. ventilators) are among the most complex and challenging to care for in the nursing home setting, they naturally receive the highest level of reimbursement. This financial incentive has motivated some facilities to evaluate whether they should develop ventilator units.

However, it would be a mistake to look only at reimbursement without giving serious consideration to the cost of providing the care as well as the ability to provide it dependably, reliably, and with good quality.

Here are just a few considerations to review before making the important decision of adding a ventilator unit to your nursing home. The list below results from my professional experience as a former Medical Director of a ventilator unit in a nursing home (SNF).

• Your SNF will need to have a medical director who is a Pulmonary specialist. In my community of about 20 pulmonary physicians at the time, I was the only one willing to accept this position and care for these highly complex patients in a SNF setting. Does your community have a Pulmonary specialist who available to you as a Medical Director, and are you prepared to meet this contractual cost?
• Your SNF will need to align itself with a company who provides registered respiratory therapists full time and who work well, as a team, with your staff.
• During periods of staff shortage, you must still be able to provide competent and specially trained staff to manage your ventilator patients. Agency staff will not meet this requirement.
• Is your SNF prepared to provide continuous staff training on the special skills needed to care for ventilator patients?
• Many patients will have antibiotic resistant infections, as most will have been in hospitals or other institutional settings for a long time and have experienced many different infections and frequent antibiotic exposure and treated with many different antibiotics.
• Antibiotic resistant infections mean, in most cases, that patients will not be able to share rooms and will require a single room. If several of your patients are involved, this can severely reduce your operational capacity. That is, you planned on a 20-bed unit, but due to the resistant infections, your capacity may be reduced to as low as 10 beds.
• There must be continuous staff monitoring and training to assure adherence to isolation precautions, policies, and procedures.
• The antibiotics used to treat these resistant infections are often extraordinarily costly. Is your SNF prepared for sticker shock?
• There will be much additional supplies needed to care for these patients, e.g. abundant gowns and gloves for patients who are in isolation, wound care supplies, respiratory supplies of various kinds, ventilator rental, etc. These supplies will add significantly to your overhead.
• Many ventilator patients are morbidly obese and will require special equipment and continuous staff training for routine care.
• There will be increased employee injury rates when caring for the morbidly obese, and that may significantly increase liability costs.
• Does your SNF have a wound care nurse? Is your SNF prepared to deal with all the skin care issues with patients who are chronically bedridden? This especially includes the skin around the tracheostomy site which will have chronic and persistent skin break-down because of the presence of the trach tube constantly traumatizing the surrounding skin.
• Most or all ventilator patients will require frequent intravenous access. In most cases, this will require a PICC line (peripherally inserted central catheter) which is costly. Does your SNF have the ability to have these catheters inserted onsite, or will the patient need to be transported to and from a local ER or radiology department to have this done? If the latter is true, is your SNF prepared to pay for services that will include: ACLS ambulance due to the presence of the ventilator, ER charge, cost of supplies and insertion of PICC line, and then staff training for proper care and maintenance of PICC line in your SNF.
• Transporting a morbidly obese patient who is ventilator dependent and has no iv access is very risky. Is your staff and your Medical Director prepared to accept these risks?
• Your SNF must have the ability to arrange for onsite chest and abdominal flat plate x-rays.
• All of your ventilator patients will have a tracheostomy ("trach") tube. Is your staff prepared to assess and treat the emergency loss of the airway (the trach tube “falls out” or becomes suddenly obstructed or mal-positioned or is bleeding)? Is your staff trained to replace or routinely change trach tubes? Is your Medical Director and his call partners prepared to answer urgent calls when a patient’s airway has become compromised and the patient is unable to breathe?
• Nearly all of your ventilator patients will have stomach tubes of one kind or another that will be inserted directly through their abdominal wall. Is your staff trained in managing patients who require tube feeding?
• There are routine problems with managing these tubes – infection of the surrounding skin, erosion of the skin from the constant tugging on the tube that occurs when the patient changes position or the bedding is changed, skin ulcers due to trauma and irritation from the tube, cellulitis from chronic exposure of the skin to stomach acid, obstruction of the tube preventing feeding or medication administration, the tube “falling out” when the patient is rolled during routine care, and many other issues. Is your staff trained and competent to assess and manage these issues? Do you have general surgeons or GI specialists available to assist in the management of these stomach tubes, including changing them routinely?
• In many/most cases, ventilator patients are CHRONIC and will ultimately transition to Medicaid. Some may already be on Medicaid prior to arrival to your facility. Once they have exceeded their 100-day Medicare benefit, many will remain with you for the rest of their lives, since they will have no place else to go and no one else capable of caring for them. Is your SNF prepared for this?
• Some ventilator patients will be younger, perhaps as young as in their 20s or even younger still. They will need you due to disabilities, traumatic brain injury, or other medical issues. In fact, during my tenure as Medical Director of a ventilator unit, a local hospital wanted to transfer a ventilator dependent infant to us who had multiple birth defects. Is your SNF prepared to deal with this? Are you prepared to manage the very young and the very old and everything in-between?
• Will your staff be trained to care for all the other chronic diseases these patients will bring to your unit?
• Most ventilator patients also have a lot of anxiety (understandably so). Do you have clinicians immediately available and competent to treat acute and chronic anxiety or other behavioral problems that will cause these patients to experience acute respiratory distress? Is your staff trained in the use of non-pharmacologic treatment of anxiety and behavioral issues?
• Is your staff and nearby residents prepared for the bothersome noise that will now be in your SNF caused by oxygen concentrators or other compressors that will be running 24/7?

These are just a few of the many issues to be considered thoughtfully when contemplating a ventilator unit in a nursing home. I would be happy to share my experiences with those who may have questions about this topic. Just e-mail: [email protected].

Dr. Steven Fuller is a triple board-certified physician/entrepreneur who develops programs in support of an Integrated Care model of senior housing. This model includes 3 equal, interactive, and mutually supportive team members: real estate, hospitality, and healthcare. He is president of Illumination Analytics and a Six Sigma Green Belt.