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Friday, June 26, 2015

Patient Care is Incompatible with Branding

The branding of hospitals, rehabilitation centers, and out patient clinics from a revenue generating perspective has been and remains successful. The downside to selling a brand is that patient care is secondary to profit. Do not misunderstand me. There are without question dedicated and excellent health care workers in every hospital and rehabilitation center in the country. Physicians exist who deeply care and enhance the quality patient lives and can help shape an independent future. There are countless wonderful physical and occupational therapists that teach people post spinal cord injury life lessons. This was true in 1978 the year I was paralyzed. It is equally true today nor is such dedication limited to those that work with people who experience a SCI. For example, I vividly recall a speech therapist working with my father after he had a stroke. My father was depressed and did not want to talk. This therapist asked me "what excites your father?" I suggested she ask and talk about horses (my Dad owned thoroughbreds). To communicate about the horses one needs to be able to read the Racing Form, the Bible of thoroughbred racing.  And that is exactly what she did--she established a thoroughbred vocabulary undoubtedly on her own time. As a result, my father's speech rapidly improved because he had something of substance to talk about. I could tell countless stories about health care professionals who went above and beyond what any person could have expected.

I cannot stress this enough: my concern with branding has nothing to do with health care workers that provide primary care but rather the institutional system in which they work. The prime flaw as I see it today with physical rehabilitation post spinal cord injury is the length of stay (LOS). A vast literature exists on LOS but the general consensus is post SCI a person circa 2015 receives about 55 inpatient days at a rehabilitation center. There is no question LOS has decreased significantly.

The decrease in rehabilitation duration is found for all SCI impairment categories. For patients with incomplete paraplegia, median LOS decreased from 68 to 29 days, and it was reduced from 84 to 42 days for patients with complete paraplegia. Median LOS was reduced by two-thirds for those with incomplete tetraplegia (from 104 to 34 days), and almost as much for patients with complete tetraplegia (from 142 to 59 days). The pressures of managed care, as much as improvements in medical and rehabilitative expertise, seem to have driven the rehabilitation LOS declines.
LOS is the tip of the proverbial iceberg for what constitutes rehabilitation today post SCI. What is deeply worrisome is the degree to which branding directly impacts patient care. My concern is what takes place during the 55 days one is an inpatient at a rehabilitation facility. What is the intensity of rehabilitation? What is the nature of the rehabilitation process? Does a patient get one on one care or are patients with a similar level of injury given group therapy sessions? The article I quoted above is the first study explore what happens during the 55 inpatient rehabilitation days one can expect to receive. Link: It would be interesting to know how many hours were spent on various types of care but that only addresses issues directly related to the body and fits squarely within the medical model of disability. How, I wonder, does a young man adapt to SCI without any exposure or knowledge about disability?  Consider a young man, 18 to 25 years old, who experiences a sudden SCI. One day he is walking around like others and in the blink of an eye is paralyzed. How much time does this man have to adapt to SCI? Less than 55 days. This is not humanly possible. This is evidenced by the fact over 64% of people post initial injury are readmitted to the hospital within 30 days of being discharged. 
Rehabilitation centers are not shy about selling the idea they have a unique brand to offer potential patients. Indeed, google the words branding and rehabilitation and a plethora of rehabilitation centers will appear. Examples abound:

From Nebraska:

Madonna Rehabilitation Hospital, a national leader in rehabilitation care and research, has modernized its branding and developed a new website to help individuals quickly access accurate information.
In partnership with Lincoln-based marketing communications firm Thought District, the hospital began the rebranding process by researching the opinions of employees, former patients and families, as well as physicians, insurance providers and discharge planners.

Spinal Cord Injury Recovery

Our spinal cord injury treatment focuses on mobility.  Our patients who have spinal cord injuries have a unique desire to improve.  Our recovery program helps patients regain their independence and reach their maximum potential.  Since every injury is unique, the treatment plan is also unique.
The most efficient treatment options are the ones that fit the needs of each unique individual.  We begin Spinal cord rehabilitation after a patient is medically stable following a spinal cord injury (SCI).  A person who has a spinal cord injury may experience a complete or partial loss of motor functioning due to a severed or partially damaged spinal cord. The difference in SCI care at Eagle Crest Care Center spinal cord injury rehabilitation center is derived from our team of experienced medical professionals who implement active, individualized care plans that concentrate on improving a patient’s functionality and mobility.
Different treatments may include:
  • Teaching patients how to maneuver a wheelchair in a store
  • Prepare meals
  • Bathing with little-to-no outside assistance.
Throughout the treatment and In the end, they gain more than just increased mobility, greater independence, and confidence to help them reach their recovery goals. At Eagle Crest Care Center, we have the unique opportunity to help SCI patients achieve a higher quality of life in a home-like, community-based environment that is designed to promote emotional well-being and physical comfort.

From Shepherd Rehabilitation, Atlanta

Shepherd Center is a brand that is fortified by the actions we take every day. It encompasses the services we provide, the respect and compassion we show patients, families and fellow employees, and the pride we share for working in an environment that is a Center of Excellence. Our brand
is reflected in the communications we develop, such as letters, hospital literature, faxes, forms, banners or T-shirts.
You play a crucial role in sustaining the strength of the Shepherd Center brand. The materials you create to communicate with internal or external audiences offer an opportunity to reinforce our brand positioning through consistent usage of the logo, color palette and typography.
Shepherd Center relies on individuals like you to serve as brand stewards. By understanding these concepts--and the applications specified in this document – you help protect the qualities and attributes important to our image.

I find the prominent branding of rehabilitation disturbing. One is not just a potential patient because  once admitted a person represents the hospital brand itself. Does this mean those individuals in need of inpatient rehabilitation that do not reflect the brand are turned away? Does the brand determine care and its focus? I think so. At issue is not just one rehabilitation facility but rather all of rehabilitation itself. Consider Kessler Rehabilitation in New Jersey, a high profile facility. Christopher Reeve went to Kessler in 1995 after he experienced a high cervical injury. Founded in 1949 with just 16 beds, by the 1980 Kessler had expanded exponentially. By 1990 Kessler had 322 beds, a dizzy array of out patient facilities, and was designated a "Model System". In 2003 Kessler was acquired by Select Medical.  Select Medical itself experienced signifiant growth in the mid to late 1990s and Forbes listed it as one of the best managed companies in the nation. Growth for Select Medical has been continuous.  Today, Select Medical owns long term acute care, inpatient medical rehabilitation, out patient physical therapy and contract therapy, and employees 30,000 people. Select Medical owns a "family of brands" in 32 states. As I read this history I thought, first, its founders must be extremely wealthy, and second, what a well greased skid an individual could find himself on. Acute care provided by the Select Medical. Rehabilitation provided by Select Medical. Out patient care provided by Select Medical. Perhaps even long term care (nursing home) provided by Select Medical.  All this could be done with the human being treated unaware one corporation determined their care. 

In terms of patient care post SCI, my concern is two fold: first, contract work is often short term. Employees come and go. I read many reviews written by health care professionals about working for Select Medical. To many state that productivity is more important than patients they treat. The work environment is stressful. Benefits are minimal. Concerns and suggestions to improve the therapeutic environment get lost between and facility and the corporation. Understaffing is common and many complained about the lack of raises if one remain at one facility for a long period of time. One former employee sourly noted "Most operations are run on shoe string budget which doesn't always jive well with patient care needs. Challenging to walk the tights rope of corporate expectations, patient care and staffing requirements. Maintaining morale and collaborative efforts between staff an management strenuous".  Second, with just 55 days of rehabilitation people who experience a SCI do not establish the sort of life long relationships I did. Rehabilitation is too short and precludes closeness with staff. Beyond time the pressure brought to bear on PTs, OTs, and nurses is a major problem. Patient care and a focus on profit are and always will be incompatible. Despite the great advances and hard work of health care professionals doing the hard work with patients I must say I yearn for the old days. There was no talk of cure or complaints about management. There was one expectation for health care workers and patients. Work hard and all shared the same goal: independence and a renewal of one's life with the dedication and support of staff. 


Matthew Smith said...

In the UK there are a lot of branded private health institutions which do contract work for the NHS. Particularly in the mental health sector although perhaps in other areas. It doesn't improve the care one bit. There was a young lady called Stephanie Bincliffe who was autistic and was put into a private mental health unit after she attacked a boy in a shop. She was kept in one room for seven years and ended up dying of complications of obesity. That really did not have to happen; it was down to the incompetence of the people 'caring' for her.

I've also heard of them suddenly discharging a patient when there was publicity about the circumstances of their detention, in one case (last month, involving a 13-year-old girl!) without making sure there was care available for her when she was at home. We have a National Health Service here and it ought not to be relying on these profiteers.

Middle Child said...

Our system is in Australia that almost without exception Spinal injuries and illnesses are only treated in Public Hospitals which are funded by Medicare - treatments should be free to all. It was a good system once but has gotten worse and Research seems to get the big dollars. I watched what was once an excellent Spinal Unit in 1982 - with in hospital daily Physio and Rehab - once discharged you were ready to go home and were given help to find accessible housing if like us you had no place to go because of the steps - now if you are very badly injured some are encouraged to die; less time is spent in care... and whist in hospital Physio seems to be less and rehab is out of the hospital and not begun till you are months down the track... there are good docs and nurses but sadly when we were last in there was not one doctor who gave a dam which is really what killed my husband. I wrote to the doctor (now retired) who began the unit and he sadly agreed with how bad things had become. Unsure how it is in other hospitals but this is a major Sydney Hospital Royal North Shore.