Identifying challenges and opportunities for the long-term care medical practitioner.

NC Med J March/April 2010, Volume 71, Number 2 I am a “SNFist” or a “SNFologist.” That is to say that I devote my full-time medical practice to taking care of residents and patients in long-term care (LTC) facilities. Firsthand knowledge and daily interactions with patients in various settings and different facilities has allowed me to gain insight into some of the challenges and opportunities of caring for residents in LTC facilities such as skilled nursing facilities (SNFs). Currently, most of the residents I care for in skilled nursing facilities comprise two larger groups. The first is described as “post acute care.” As hospital stays have become shorter in recent years, the SNF has become an important and useful intermediary step in the transfer of residents from inpatient hospital care towards returning to their home setting. Common examples of this group include residents who suffered traumatic injuries, significant surgical interventions, elective orthopedic procedures, or debility and deconditioning, where patients are unable to safely perform their activities of daily living (ADLs) within the limitations or circumstances of their domiciliary arrangement. The second group of residents in most skilled nursing facilities is what most people commonly associate with a nursing home resident. These are residents that reside long-term in a facility for daily assistance and management of their medical problems and ADLs. Returning home is not a practical or safe alternative for these patients. Circumstances that usually preclude a transition to a SNF include the availability of social support, frailty, and chronicity of medical problems. One big challenge in meeting the needs of these two groups is the constraints of the physical facilities themselves; many were set up, designed, and built in the distant past. Residents and families in the post acute care setting, who are working towards returning home, usually prefer to live in private rooms, which are not readily available. Some buildings have a specific area devoted to rehab patients; others do not. Sometimes patients in a facility for a shortterm stay have to share space and areas with residents with entirely different needs. There is currently a national trend developing to convert and change the physical set up of some facilities to a ‘residential/community’ structure. In this arrangement, instead of all residents sharing a pool of interdisciplinary teams (e.g., patient care, nursing, dietary, laundry), residents reside in smaller subgroups within the facility, usually called neighborhoods, and are cared for by a smaller, more familiar core care team that share the duties of the interdisciplinary team with a smaller group of residents. The difficulties of retrofitting older facilities and building new facilities to accommodate this patient structure are major challenges in moving to this neighborhood concept.