When Joyce Deno Thomas, now senior vice president for Regent Surgical Health, was administrator at Loveland Surgery Center, she helped develop a convalescence center that allowed surgeons to perform higher acuity cases at the ASC.
After their procedures, patients were discharged to the convalescence center connected with the ASC. Now, Administrator Sonia Foote continues to grow and develop the center to take care of patients.
"The attraction for convalescence centers is that quite often surgical patients simply need a place to regain some strength and have pain controlled," says Ms. Foote. "This doesn't necessarily require full hospital services. A convalescence center allows patients to stay for 72 hours [or more] in a separately-licensed facility until they are ready to return home."
Developing the convalescence center
The convalescence center needed separate licensing from the ambulatory surgery center according to Colorado state regulations. Additional considerations are necessary for accommodating patients who are staying overnight, especially if they will be spending multiple nights.
Each facility needed its own narcotics, drugs and resuscitative equipment. Patients are discharged fully from the ASC and reassessed with new paperwork before admittance into the convalescence center.
"When I initially sat down with our director of nursing, we realized that we weren't just creating more recovery rooms; the center is like a mini-hospital," says Ms. Thomas. "If you are going to keep patients overnight or up to 72 hours, you have to understand what the patient needs."
Security is also an important issue for patients and nurses staying after hours. The building is kept on lockdown and people are unable to see the nurse's desk from the outside door. Staff are not allowed to enter or exit the building at night — not even to smoke — and a security guard drives by the center several times per night.
"We also had an anesthesiologist and surgeon on call at night, although we didn't have a surgeon onsite," says Ms. Thomas. "They were typically within five miles of our facility if an emergency occurred."
Philosophy of care
The foundation of the center's philosophy was that the patient should never have to ask for anything; the nurses were ready with pain medication, water, food or other comfort items and trained to anticipate these needs. The nurses were also directed to follow the surgeon's directions exactly.
"If the surgeon said to have the patient ambulate at eight hours, that's what we did," says Ms. Thomas. "Because we were aggressive with nursing care here and followed surgeon orders, things didn't get out of control. The surgeons told us stories where patients don't ambulate for four or five days after surgery in the hospital. That can lead to complications, but we never had any."
Ms. Thomas and her team decided to staff the convalescence center with one nurse for every two patients at all times, and include a nursing assistant even over night. The center had four beds and often operated at 80 percent capacity Monday through Friday while Ms. Thomas was with the center.
"You want to have a strong nurse-to-patient ratio for safety," she says. "We didn't want to scrimp on staffing. Our patients who were undergoing one- or two-level lumbar fusion with an average stay of a day-and-a-half experienced no complications or transfers because my nurses were dedicated to providing good care."
The nurses were also encouraged to spend as much time with the patient as possible, even if it meant bringing their charts into the patient's room and finishing paperwork there. "I wanted the patients and nurses to see each other so there was no lapse in communication and the surgeon's orders were always implemented at the exact time," says Ms. Thomas. The surgery center and convalescence center outside of the hospital have additional benefits for recovery.
"The physicians appreciate their patients have more personalized care and attention," said Ms. Foote. "There is also less risk of infection than in the hospital setting."
Amenities
If patients are staying at the center for an extended period of time, they'll need meals three times a day plus snacks, private restrooms and other accommodations. When Ms. Thomas first opened the convalescence center, they catered in from a local restaurant. However, special dietary needs were often unmet and she then contracted with a dietician to develop a breakfast, lunch and dinner menu appropriate for the center's patients. She followed up with a caterer who provided a consistent three choice meal option.
"We had a dietary book where the dietician broke down each menu item with calories, fat content and sodium so we could validate what patients were given," she says. "The patients received a pretty menu and checked off the items they wanted. We had a caterer deliver their meals to the facility and we'd heat them to the appropriate temperature before delivering them."
Everything is recorded, including the temperature of the food. The kitchen has a dishwasher with a temperature booster to ensure dishes are cleaned at the appropriate sanitation levels. While paper plates might be more convenient, patients are excited to have real dishes and silverware available.
The refrigerator is also stocked with snacks and dishes rotate out to make sure everything is fresh. "We felt we had gone the extra mile to make sure there was good quality food going out to our patients," says Ms. Thomas. "We also spent time to make sure our rooms were beautiful with good mattresses on the bed. Every meal came with a budvase of flowers."
While the little things cost about an extra $15 per day, patients are very complementary of the center.
Physical therapy and rehabilitation
The recovery process for spine surgery begins immediately and patients taking a few extra days at the center will need physical therapy services. Ms. Thomas arranged a consultant physical therapist to speak with patients about biomechanics, ambulation and teach them how to use their walkers. "The patients love getting outside when the weather is nice and walking every two to four hours," says Ms. Thomas. "We had a nurse with them every step of the way."
The center also contracts with a respiratory therapist. As the program became more developed, nurses began discharge planning prior to the day of surgery. During the preoperative telephone contact the nurses would ask patients about returning home postoperatively to make sure they'd be able to recover safely. Patients with bedrooms upstairs might need a hospital bed installed on the main floor. Others who don't have a ride to outside physical therapy need therapists to make home visits. In addition, the nurse asked the physical condition of their caregiver to ensure the patient would have help as needed.
"As the discharge planning developed and needs were identified, the nurse would arrange to have the hospital bed delivered or physical therapy arranged before the day of surgery," says Ms. Thomas. "If you're doing complex spine, hip and knee procedures, you want to make sure everything is ready for the patients to go home as soon as possible."
A trend of the future?
State regulations prevent convalescence centers attached to ASCs in all but a handful of states currently; however, with more focus on saving healthcare dollars, more states may come onboard in the future. Convalescence centers such as the one connected to Loveland Surgery Center have the potential to provide higher quality care at a lower cost than hospitals.
"I think the convalescence center is the way of the future to keep patients out of the hospital where there is a higher risk of complications and the nurse-to-patient ratio is much less favorable," says Ms. Thomas. "If they really measure the outcomes from the convalescence centers that currently exist — and leave politics out of it — they would find that the quality of care is there and costs are low."
The convalescence center will continue to allow surgeons to bring higher acuity cases into the outpatient setting. "Having the convalescence center opens up the possibilities for simple thyroidectomies that may need more than an overnight stay," says Ms. Foote. "We do spine cases now that require a longer stay. Additional gynecology cases such as vaginal hysterectomy would also be ideal for a facility like this."
However, it remains a challenge to receive coverage from payers. Depending on the region of the country, some payers may be more amicable than others.
"You need to work with payers to carve out CPT codes," says Ms. Foote. "Codes that typically required procedures be done in the hospital are now transitioned to the ASC. You also need coverage for the overnight stays. It hasn't been hard for us to make the argument for coverage with the payer because the surgeries cost so much more in the hospital."
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After their procedures, patients were discharged to the convalescence center connected with the ASC. Now, Administrator Sonia Foote continues to grow and develop the center to take care of patients.
"The attraction for convalescence centers is that quite often surgical patients simply need a place to regain some strength and have pain controlled," says Ms. Foote. "This doesn't necessarily require full hospital services. A convalescence center allows patients to stay for 72 hours [or more] in a separately-licensed facility until they are ready to return home."
Developing the convalescence center
The convalescence center needed separate licensing from the ambulatory surgery center according to Colorado state regulations. Additional considerations are necessary for accommodating patients who are staying overnight, especially if they will be spending multiple nights.
Each facility needed its own narcotics, drugs and resuscitative equipment. Patients are discharged fully from the ASC and reassessed with new paperwork before admittance into the convalescence center.
"When I initially sat down with our director of nursing, we realized that we weren't just creating more recovery rooms; the center is like a mini-hospital," says Ms. Thomas. "If you are going to keep patients overnight or up to 72 hours, you have to understand what the patient needs."
Security is also an important issue for patients and nurses staying after hours. The building is kept on lockdown and people are unable to see the nurse's desk from the outside door. Staff are not allowed to enter or exit the building at night — not even to smoke — and a security guard drives by the center several times per night.
"We also had an anesthesiologist and surgeon on call at night, although we didn't have a surgeon onsite," says Ms. Thomas. "They were typically within five miles of our facility if an emergency occurred."
Philosophy of care
The foundation of the center's philosophy was that the patient should never have to ask for anything; the nurses were ready with pain medication, water, food or other comfort items and trained to anticipate these needs. The nurses were also directed to follow the surgeon's directions exactly.
"If the surgeon said to have the patient ambulate at eight hours, that's what we did," says Ms. Thomas. "Because we were aggressive with nursing care here and followed surgeon orders, things didn't get out of control. The surgeons told us stories where patients don't ambulate for four or five days after surgery in the hospital. That can lead to complications, but we never had any."
Ms. Thomas and her team decided to staff the convalescence center with one nurse for every two patients at all times, and include a nursing assistant even over night. The center had four beds and often operated at 80 percent capacity Monday through Friday while Ms. Thomas was with the center.
"You want to have a strong nurse-to-patient ratio for safety," she says. "We didn't want to scrimp on staffing. Our patients who were undergoing one- or two-level lumbar fusion with an average stay of a day-and-a-half experienced no complications or transfers because my nurses were dedicated to providing good care."
The nurses were also encouraged to spend as much time with the patient as possible, even if it meant bringing their charts into the patient's room and finishing paperwork there. "I wanted the patients and nurses to see each other so there was no lapse in communication and the surgeon's orders were always implemented at the exact time," says Ms. Thomas. The surgery center and convalescence center outside of the hospital have additional benefits for recovery.
"The physicians appreciate their patients have more personalized care and attention," said Ms. Foote. "There is also less risk of infection than in the hospital setting."
Amenities
If patients are staying at the center for an extended period of time, they'll need meals three times a day plus snacks, private restrooms and other accommodations. When Ms. Thomas first opened the convalescence center, they catered in from a local restaurant. However, special dietary needs were often unmet and she then contracted with a dietician to develop a breakfast, lunch and dinner menu appropriate for the center's patients. She followed up with a caterer who provided a consistent three choice meal option.
"We had a dietary book where the dietician broke down each menu item with calories, fat content and sodium so we could validate what patients were given," she says. "The patients received a pretty menu and checked off the items they wanted. We had a caterer deliver their meals to the facility and we'd heat them to the appropriate temperature before delivering them."
Everything is recorded, including the temperature of the food. The kitchen has a dishwasher with a temperature booster to ensure dishes are cleaned at the appropriate sanitation levels. While paper plates might be more convenient, patients are excited to have real dishes and silverware available.
The refrigerator is also stocked with snacks and dishes rotate out to make sure everything is fresh. "We felt we had gone the extra mile to make sure there was good quality food going out to our patients," says Ms. Thomas. "We also spent time to make sure our rooms were beautiful with good mattresses on the bed. Every meal came with a budvase of flowers."
While the little things cost about an extra $15 per day, patients are very complementary of the center.
Physical therapy and rehabilitation
The recovery process for spine surgery begins immediately and patients taking a few extra days at the center will need physical therapy services. Ms. Thomas arranged a consultant physical therapist to speak with patients about biomechanics, ambulation and teach them how to use their walkers. "The patients love getting outside when the weather is nice and walking every two to four hours," says Ms. Thomas. "We had a nurse with them every step of the way."
The center also contracts with a respiratory therapist. As the program became more developed, nurses began discharge planning prior to the day of surgery. During the preoperative telephone contact the nurses would ask patients about returning home postoperatively to make sure they'd be able to recover safely. Patients with bedrooms upstairs might need a hospital bed installed on the main floor. Others who don't have a ride to outside physical therapy need therapists to make home visits. In addition, the nurse asked the physical condition of their caregiver to ensure the patient would have help as needed.
"As the discharge planning developed and needs were identified, the nurse would arrange to have the hospital bed delivered or physical therapy arranged before the day of surgery," says Ms. Thomas. "If you're doing complex spine, hip and knee procedures, you want to make sure everything is ready for the patients to go home as soon as possible."
A trend of the future?
State regulations prevent convalescence centers attached to ASCs in all but a handful of states currently; however, with more focus on saving healthcare dollars, more states may come onboard in the future. Convalescence centers such as the one connected to Loveland Surgery Center have the potential to provide higher quality care at a lower cost than hospitals.
"I think the convalescence center is the way of the future to keep patients out of the hospital where there is a higher risk of complications and the nurse-to-patient ratio is much less favorable," says Ms. Thomas. "If they really measure the outcomes from the convalescence centers that currently exist — and leave politics out of it — they would find that the quality of care is there and costs are low."
The convalescence center will continue to allow surgeons to bring higher acuity cases into the outpatient setting. "Having the convalescence center opens up the possibilities for simple thyroidectomies that may need more than an overnight stay," says Ms. Foote. "We do spine cases now that require a longer stay. Additional gynecology cases such as vaginal hysterectomy would also be ideal for a facility like this."
However, it remains a challenge to receive coverage from payers. Depending on the region of the country, some payers may be more amicable than others.
"You need to work with payers to carve out CPT codes," says Ms. Foote. "Codes that typically required procedures be done in the hospital are now transitioned to the ASC. You also need coverage for the overnight stays. It hasn't been hard for us to make the argument for coverage with the payer because the surgeries cost so much more in the hospital."
More Articles on Surgery Centers:
7 Recent Leadership Moves Within the Surgery Center Industry
ASC Physician Engagement: Tips for Communicating With Physician Owners
How Will Hospital Employment Impact ASCs in the Future?