Rehab with Heart

Theresa Schultz is on her way to Washington, D.C., flying in a bone-white puddle jumper. As it wobbles up through the crosswinds and gray storm clouds swirling over Cleveland, the plane's exposed twin black propellers hum loudly, unconvincingly—a nerve-racking distraction to most everyone seated on this dreadfully small aircraft. But Schultz carries on her conversations with a resilient focus, the importance of the trip hanging heavy on her tongue.

The American Heart Association recognized her as one of 10 advocates from Ohio to help lobby during tomorrow's April 2011 You're the Cure on the Hill campaign, pushing for legislation and the appropriation of funds to aid in the prevention of heart disease and stroke. Schultz, RN, and the director of care delivery at ManorCare Health Services – Rocky River in Cleveland, is responsible for a 32-bed cardiac recovery unit at the skilled nursing and rehabilitation facility that has quickly made her a figure of rising stature within and outside of her organization. It's why the American Heart Association plucked her from long-term care to help be a voice for a preventable cause.

“I'm not anyone up high on the food chain,” she explains. “I'm just a nurse director that cares a lot about her patients and I've found a different way to bring information to them and embrace this healthcare reform piece.”

The reform piece of which she speaks is that little matter of reducing unnecessary hospital readmissions, the animus of so much taking place in the framework of care quality discussions and healthcare delivery. Schultz's tactic involves a multidisciplinary approach to reducing those readmissions through comprehensive patient education—her “different way” of bringing information to patients in her facility's cardiac recovery program.

“Heart patients are heart patients for life,” Schultz states with conviction, as if she has said this exact phrase every day of her life. “If you can teach people how to change their lives by what they're eating, by exercising, and by taking their medication, it's huge.”

ANATOMY OF RECOVERY

The Centers for Disease Control and Prevention estimate that every 25 seconds, an American suffers a “coronary event.” Heart disease is the number one cause of death for a variety of reasons, one of which involves the cyclical behavior of individuals making poor personal choices. Healthcare organizations have therefore targeted heart failure readmission reduction programs as necessities, and a 2009 survey conducted by the Healthcare Intelligence Network found 77.6 percent of organizations identify heart failure as a top condition guiding their readmission reduction efforts. This is where Schultz's cardiac recovery program stands out, because the tools and initiative to live a healthier life are placed right into the patient's hands.

When someone is admitted to ManorCare Health Services – Rocky River with a cardiac primary diagnosis, they are put on the facility's vigilant cardiac protocol. How vigilant is it? If a patient sees a two-pound weight gain in one day, or a five-pound weight gain in one week, his or her physician is notified. If the patient experiences chest pain, an EKG can be performed on the spot. And if he or she has a central line, labs can be run onsite as well. The skilled nursing facility is connected to the Cleveland Clinic's DrConnect, an Internet-based service allowing community physicians to view real-time electronic medical record information about their patients, which makes this particular ManorCare unique, Schultz says. But EKGs and EMRs don't keep a patient from returning to the hospital once they have left Schultz's realm, which is why patient education has become the mantra around these parts.

“If the patient is not compliant with their disease process, they're going to go back to the hospital,” argues Jody McConnell, administrator at ManorCare Health Services – Rocky River. “Nursing homes can be doing a much better job of educating these patients.” And that is easy to say when you have a team like the one assembled at this location, which features not one but three nurse practitioners who allow the facility to accept patients of increasingly high acuity; a consulting cardiologist in Muhammed Zahra, MD, who makes regular visits to assess cardiac patients and provide recommendations to prevent further hospitalization; and a full, caring staff that has bought into education as a part of the ongoing rehabilitation process.

THE FOUR ELEMENTS

At its core, Schultz's patient education program encourages heart healthy decision-making in four key areas: exercise, label reading and menu planning, cooking, and medication. A 30-minute class dedicated to one of the four areas is held within the facility once a week. The approach is multidisciplinary and involves the department managers from nursing, therapy, activities and dietary.

First is the head-to-toe exercise routine, designed by Activities Director Barbara Bliss, a former physical education instructor. The exercises, which are easy to remember, can be performed in some capacity by anyone—even those with limitations or disabilities—standing up, sitting in a wheelchair or lying in bed. Exercises include arm circles, ankle circles, punches, twists and cleansing breaths.

Doris, a 70-year-old patient in the program, shows off her favorite move. “The one I like—what do teenagers say nowadays?” Doris shrugs her shoulders as if to mimic a sheepish youngster. “‘I don't know….’” The “I don't know” shoulder shrug is noteworthy in that it embodies the program's simplicity, encouraging patient participation and, by extension, faith in the program itself. “I'm gone,” Doris says of her ability to leave in the coming days. “Not that they're not nice here, but I'm going home. I have every confidence in them.”

When Doris does go home, she'll have been educated on how to read labels and plan her meals, the second component of the program. Dietitian Sue Kocin instructs patients on what foods to eat and what to avoid, with each choice founded on two governing principles: it must be low in sodium and low in cholesterol. Kocin circulates a box of emptied canned and boxed goods among patients showing what common processed foods, such as high-sodium soups and macaroni and cheese, should be thrown out of their cupboards.

The third class takes place in the facility's occupational therapy kitchen, where patients cook with one another and staff. “We have a discussion while we are cooking about heart healthy facts, and it gives our occupational therapist [Karla Reese] the potential to capture those therapy minutes,” Schultz says.

Finally, Schultz herself takes on medication instruction in the fourth class, which focuses on diuretics and cholesterol meds, among others. All of the classes impart practical advice to help patients lead healthier lives once they are at home, but the education does not cease at the end of each half-hour session. Schultz and her team members are constantly engaged in one-on-one education with patients, with varying levels of detail depending on individual needs. “The teaching process starts from the minute they come in the door until they leave,” Schultz says, “so they need to be getting individualized instruction from either myself or one of the nurses on the floor or one of the department heads.”

Schultz also supplements her program with printed booklets from Krames, a company that produces patient education materials in both print and digital formats. Some of the Krames booklets given to these cardiac patients cover the basics of understanding heart failure and coping with chronic obstructive pulmonary disease (COPD). While the materials are written for an acute care audience, Schultz says the information within them is universally helpful. This is indeed complementary, as her overall approach is to provide patients with simple solutions. It's not a lofty objective, but an effective one.

“We're not going to change someone into a different person,” says Dan Rivera, administrative director of nursing services, who operated the cardiac unit before hiring Schultz. “If you can improve one or two things [for patients], you can increase their quality of life.” And hopefully keep them from being readmitted to the hospital.

This is not to say, though, that managing an education program within a complex cardiac recovery unit comes without challenges. As the administrator, McConnell is able to witness the toll this work takes on staff. For example, because of the facility's advanced clinical skills, McConnell “never hesitates” when accepting high-acuity patients. That high acuity does eventually wear on staff members, she admits, “and it is frustrating to see patients make bad choices” when you've spent the better part of a month or longer teaching them how to be responsible with their health.

Schultz comes from education; she was a nurse within the Cleveland Clinic system for 10 years as well as a nurse with the MetroHealth system in Northeast Ohio—education is at the “forefront” of these organizations, so it is second nature for her to want to teach. She also expects herself to continually be innovative.

“For instance, I had a patient who did not go to school,” Schultz explains. “She couldn't read or write. I had to come up with a way to communicate meaningful information to someone who was very limited in how they can learn. Some people learn by instruction, by hearing, by doing. We have to put our heads together and figure out, what can we teach them? Because on admission, we identify what they need and adjust our program as we go along.”

By tracking patient progress and collaborating with other department heads and staff, Schultz can target weak points within the program and help it evolve—much like how health literacy itself is evolving. As more healthcare reform provisions unfold, hospitals are going to become more selective in which post-acute providers they discharge patients to, and Schultz expects a greater number of skilled nursing facilities to seek these kinds of health literacy options to help prevent readmissions.

STAR STUDENT

On the plane to D.C., Schultz can't help but thumb through folders and binders, sharing all manners of promos, white papers, even the speech she's written for tomorrow's lobby presentation. Her eyes gleam, and shooting up from the mess of printouts is a colorful patient testimonial about a man named Arthur. “Do you want to hear our success story?” She hands the paper over, unable to contain her smile, humming like that dinky black propeller on the wing outside her window.

The testimonial reads: Arthur was admitted to ManorCare Health Services – RockyRiver with fluid buildup, shortness of breath and weighing 358 pounds.

“He spent six weeks with us on our cardiac recovery program,” Schultz says of 56-year-old Arthur. “And he lost 132 pounds. He's down to 226.”

Arthur has made educated changes that will help him better manage his condition in the future.

A city blurs past, then landmarks, and the government. The descent toward Reagan National Airport follows the Potomac in what's known as the “River Visual” approach. It also means the diminutive plane is swaying to and fro as it comes closer to the water. Suddenly, violently, it jerks into an upward trajectory. People are confused. And grumbling. Then, the pilot: “Well, folks, it looks like we overshot the landing. Gonna take this back up and turn it around. Thanks again for flying on—”

And this whole time, Schultz is still talking, still teaching. Unfazed.

“That was a huge accomplishment to help that patient make those changes for himself. Arthur is still at home, he's not in the hospital and he didn't come back.”

As well it should be.

Long-Term Living 2011 July;60(7):50-54

Kevin Kolus

Kevin Kolus wrote for I Advance Senior Care / Long-Term Living when he was an editor. He left the brand in 2012. He is now senior communications manager at Cleveland Clinic.