Education and research will be intrinsic parts of the Loeb program. It is self-evident that for an institution to be successful and creative within the community, full opportunity must be given to physicians and other personnel to work in research areas of their choice within the scope of the program. Since the problems of long-term illness are of such relevance today, the Loeb Center's full potential for teaching professional staff members of Montefiore and other community agencies must be realized. The close and intimate relationship that will exist between the center and the hospital will represent an enormous advantage in the economic management of the facility. Of equal and obvious importance will be the fact that the full resources of Montefiore Hospital will be readily accessible when needed. The effect of the stimulation provided by the activities of the hospital is bound to create the kind of atmosphere in Loeb which will be a significant factor in the quality of service rendered. Not to be minimized is the general availability of hospital beds, at a moment's notice, for those patients who require immediate hospitalization. Thus, when completed and in operation, the Loeb Center will be another vital health care facility within the broad spectrum now provided under the aegis of Montefiore Hospital. It will, in effect, be another extension of the hospital into the community as are the home care program, the medical group, and the association with the Beth Abraham Home. Its mission will be to alleviate through patient care, education and research the sufferings of prolonged illness and to assist the ill, the disabled, and the handicapped to achieve maximum levels of health for productive participation in society. NURSING The concepts regarding nursing care which influence the suggested staffing pattern and program of Loeb Center consist of those which view nursing as a close interpersonal process made up of three interlocking aspects. The first of these three, the intimate bodily care is exclusive to nursing. The other two are shared. Intimate bodily care is the unique core of nursing, the heart of the nurturing process. Its main goal is the comfort of the patient, achieved through the very personal processes of bathing, feeding, toileting, positioning, moving, dressing, and undressing. These processes loom large also in the teaching of activities of daily living-the famous activities of daily living of rehabilitation through which patients learn even under handicapping conditions to again assume responsibility for their own personal care. The nurse and the specialist, often the occupational therapist, work together to assist the patient in mastering the skills of ADL-an important step on the way to restoration. Intimate bodily care is modified also in terms of the medical problems and goals, so that the medical care aspects of nursing overlie and influence the nurturing ones. Nursing through its observations assists medicine in gathering data which the physician uses along with that from other ancillary services to integrate with the data that only he is qualified to collect in order to make an accurate diagnosis. Nursing also assists medicine in carrying out the medically technical functions and tasks from the diagnostic, therapeutic and evaluative plans which physicians have delegated to nurses. In this aspect of nursing which she shares with the medical groups, the nurse, unless she takes great care becomes a painer rather than a comforter. Observations and treatment procedures are investigative as well as therapeutic and often potentially painful. With the increasing amount of medical care tasks delegated to the nurse, the greater has been her allocation of time and effort to this technical area of practice, so that she and others view her more as an assistant to the doctor in medical care rather than assisting the patient through his medical care. This is one of the factors that led nurses to delegate in turn most of the intimate bodily care aspects of nursing to practical nurses on assigned-tasks basis. Thus, the opportunity for closeness goes to a group of nursing personnel whose short training period limits their preparation in any of the sciences, let alone the most important social sciences needed to help patients use the close relationship of nurturing for understanding and growth toward a healthful state, the third aspect of the nursing process. This aspect deals with the applications from the human behavioral sciences. It is shared with all the professional persons who help the patient help himself. Here, the helper uses self therapeutically in the interest of the patient's recovery and rehabilitation. As the nurse gives up the initimate bodily care, she gives up the unique core of nursing, losing or nullifying as well the comforting closeness which other helping professions have recognized as paramount in the effective use of self, operating not merely to help her understand the person of the patient, but to help the patient see his person; i.e., find himself in relation to his social and emotional problems. Crises in these areas go along with illness and, unless resolved, slow recovery, add complications, delay rehabilitation, and according to some schools of thought are contributory, even causal to illness. As a consequence of events, then, we find nurses concentrating on the medical care aspects so that the role has become more and more that of a "practical" doctor. Her nurturing role goes to the "practical" nurse, so that patients receive from nurses "practical" doctoring and "practical" nursing. The public receives professional nursing only when the nurse is involved with the patient through the meshing of the three aspects into an integrated whole process which not only permits but facilitates the active participation by the patient in his rehabilitative program. Only as the patient participates is rehabilitation achieved. Participation requires that all professions on the rehabilitative team count the patient as an active member and work with him in a problem facing, problem solving way. Nursing with the patient requires professional preparation which conentrates on the social science application to balance the past emphases on the natural and biological ones. Working with feelings as well as with other health facts makes the situation a learning one for the patient who needs to learn who he is, where he is, where he wants to go and whether he will take or refuse help in getting there. Through this process he becomes aware of his goals and motivations. When this stage is reached, he is in a favorable position to tap his own resources and powers for healing. These professional goals of nursing differ markedly from the vocational goals of dividing the nursing work to get it done. Unification, rather than fractionalization of nursing care, is the aistinctive mark of quality nursing. It is the distinctive mark of quality nursing care which can hasten recovery reduce complications and recurrences to facilitate an early rehabilitation. For some time then, inservice education is needed to help the nurse apply sciences more effectively, with special concentration on social sciences to which she has been introduced only lately. Inservice of this nature cannot be effective with practical nurses who have had little or no introduction to these or other sciences and who cannot by means of inservice education alone be brought to competences most helpful in nursing patients who are struggling to achieve rehabilitation. The above concepts and the underlying philosophy are basic to the sugges‐ tions for staffing Loeb Center with registered nurses for the most part and to a lesser degree with aids and clerks. The latter will assist the R.N.'s with the things and the records associated with nursing care. This will free the R.N.'s to nurse the patients through rehabilitative nursing of high quality at the lowest cost possible for this important therapy. STAFFING CONSIDERATIONS The suggested budget of the Loeb Center provides for 92 persons to serve its 80 patients a staff-bed ratio of slightly better than 1:1. This includes those employees added to the Montefiore staff to help service the Loeb Center. The literature on the subject advocates a 1:1 staff-bed ratio in nursing homes. In view of the unique nature of the Loeb program demanding large amounts of nursing care, the total staff requirements projected do not appear excessive. (Over 75 percent of personnel will be involved in direct patient care.) Actually savings will accrue later from the use of consultants in the paramedical services and in the provision of many ancillary services by the hospital. In the following sections on medical care and the associated therapies and in the chapter on the budget, the staffing picture emerges clearly for all but nursing. Since the greatest number of personnel will be in nursing, a more detailed pattern is presented below. Nursing service For an 80-bed institution with 2 patient-care units, the total number of persons budgeted for nursing to provide for the staffing patterns as shown below will be 51. This does not include the executive director of the center or her assistant, both of whom will be professional nurses. The pattern for each 40-patient unit per tour of duty Monday through Friday will be as follows: A.m. tour of duty: One unit chief nurse. Five registered nurses. Two and one-half attendants (male and female). P.m. tour of duty: One unit chief nurse. Five registered nurses. Two and one-half attendants (male and female). Night tour of duty: One-half unit chief nurse. Two registered nurses. Two attendants (male and female). One ward clerk on each nursing unit, 9 a.m. to 5 p.m., Monday through Friday. One team clerk for the group unit. Weekend and holiday coverage: A.m. tour of duty: One unit chief nurse. Two registered nurses. Two attendants (male and female). P.m. tour of duty: One unit chief nurse. Two registered nurses. Two attendants (male and female). Night tour of duty: One-half unit chief nurse. One registered nurse. One and one-third attendants (male and female). Calculations indicate that a little over 4 hours of nursing care per patient-day will be given at Loeb. This corresponds roughly to the amount which now obtains at Montefiore. It should, however, be noted that a considerably larger proportion of the nursing care at Loeb will be rendered by professional registered nurses whose role has been greatly expanded. It encompasses all aspects of the nursing processes described earlier and thus comprises the chief therapy offered the patient in a family-centered approach into which public health nursing concepts are integrated. In addition, the nurse has the major responsibility of channeling the therapies of the other disciplines to reach the patient in a coordinated program of care and teaching through which he has the opportunity to heal and grow. Finally, for proper and effective administrative and professional control, it is urgently recommended that the nursing personnel at Loeb be directly and exclusively responsible to the executive director of the center. MEDICAL CARE 10 Patients admitted to Loeb will have just received intensive and definitive therapeutic and diagnostic hospital services and will be in a stage of illness which requires less intensive medical care, but still on an inpatient basis. They will no longer need the vast complex of medical and technical services that the general hospital provides. However, this broad spectrum of facilities will be quickly available to them by transfer back to the hospital if the need arises. At all times the integration of the medical care program of the center with that of Montefiore Hospital will assure the center of ready accessibility to any necessary medical specialty services. 10 See also "Job Descriptions" in app. A. The medical care program of the Loeb Center will be designed to bridge the gap between the hospital program and subsequent ambulatory or home care therapy assuring smooth transition of services. Thus, the medical care of Loeb Center will have a triple orientation: to evaluate the therapeutic plan; to amend this plan in accordance with the patient's progress toward medical goals and his own restoration, to add to the plan in terms of prevention, early recognition and care of conditions other than those for which the patient was originally hospitalized. The overall purpose of the program will be to promote maximal health of each patient. Since patients selected for Loeb Center will be those with good prognoses who are expected to return to full community and/or full family participation, the transitional program of the Center will seek to provide physicians' services in a pattern less like that of the hospital and more like that of the home and doctor's office. The frequency with which the physician is to see the patient will be outlined in his evaluative and therapeutic plan. This will vary with the individual patient. Patients requiring daily physicians' visits probably belong in the hospital. For the most part, the patient will visit a physician at scheduled intervals in the offices provided in the center. A conference with the nurses will help the patient prepare for this visit. A conference following this visit will give him an opportunity to discuss his feelings and obtain clarification of findings. Time will be made available for close family members to confer with the physician and other staff members. With professional nurses working closely with the patients, subtle signs and symptoms can be observed in the intervals between the scheduled visits and medical attention can be obtained promptly. Medical services With 80 patients involved in the Loeb Center program, and judging from the home care department's experience with medical care, it seems reasonable to employ four half-time physicians to serve the center's patients and to participate in the education and research program. Depending upon the nature of the medical research and its financing, one or more fellowships may be established. The organization of the medical staff is still under exploration to provide the most appropriate medical service for this novel situation. An important question under consideration deals with the need or not for the appointment of a medical director at Loeb. In view of the fact that the medical staff will be professionally responsible to the appropriate division or divisions of the hospital, which already function with full-time chiefs, the decision may be made to place the administration of Loeb's medical care program in the hands of one or possibly two division chiefs; for example, division of internal medicine, division of rehabilitation. All are agreed that the rotation of house staff through the center is an important and desirable goal. Whether this will become a routine residency training at Montefiore or will be on an elective basis remains to be seen. Emergency house staff coverage on nights and weekends will be arranged through the hospital. It is anticipated that the nature of the patients' illnesses and the emphasis on restoration of health will require that physicians be able to diagnose and treat conditions calling for use of the more common physical therapy modalities. For complex problems they will be able to obtain prompt and regular consultation with the staff of the division of rehabilitation of the hospital. The physical therapist assigned to the center will be supervised by this division. Any patient who needs intensive and definitive physical medicine services will not be admitted to the center but instead to the hospital's division of rehabilitation. If a center patient develops a condition requiring such care, he will be transferred to that division. In like manner, other specialists will be available for consultation to the physicians of the center and, where appropriate, patients may be transferred from the center to the hospital for definitive diagnosis or treatment. Professionally, the staff physicians will be responsible to the appropriate division of Montefiore Hospital, and administratively to the executive director of the Loeb Center for Nursing and Rehabilitation. Accommodations Accommodations will be identical for ward and for private patients, but the former will be charged more modest rates. There will be as little distinction as possible between private and ward patients regarding the type of care provided. Nevertheless, there will be certain unavoidable differences in care, mainly involving the relationship of the private physician to the permanent staff of the center. Service patients Total responsibility for the medical care of ward patients will be assigned to the medical staff. Rounds and conferences will be an integral part of the program. Consultations in any of the specialties will be arranged through the appropriate clinical division of the hospital and will involve both attending physicians and residents. Private patients Even though all private patients at Montefiore Hospital are under the medical care of a closed attending staff, the possibility of a more flexible policy for Loeb Center's private patient care was explored. Extending admitting privileges beyond the closed staff to other physicians in the community, even with the accruing mutual benefits, would favor the emergency of misunderstandings that often arise when a single exception is made to a general policy. Then, too, there could develop confusion and discomfiture of the patient and doctor alike at such times when a patient's condition necessitated a return to the hospital for care where the closed medical staff policy would have to prevail. For these reasons, the center will adopt the policy that the hospital has found so effective in providing excellence of medical care. Even with this policy in effect at Loeb, private medical care poses some problems. While there would be an advantage to terms of a more easily integrated medical program were the private physician to turn over total responsibility for care to the Loeb medical staff, a disadvantage would be noted. This would be the interruption of the established doctor-patient relationship which is often therapeutic in itself. To realize the benefits of both of these influences, it will be essential for the private physician to participate in a team relationship with all those involved in his patient's care at Loeb. The medical staff of the center will have to encourage the private physician to attend the conference when his patient's program and progress will be discussed and where suggestions and recommendations of all concerned can be considered for therapeutic action. Certainly, attendance at such conferences could be considered visits by the private physicianvisits on behalf of his patients. The participation of the private physician in the full program of Loeb Center would be beneficial to all concerned: continued doctor-patient relationship, enrichment of the center's program, experience for the doctor in a therapeutic team relationship involved in a different approach to patient care than that of the general hospital at a time in the sequence of events when the center's program becomes appropriate to a particular phase of his patient's illness. This "team" functioning and sharing of responsibility could be feasible if the physicians on the attending staff of Montefiore Hospital are properly oriented to the philosophy and program of the Loeb Center. OTHER THERAPIES OF THE PROGRAM 11 11 See also "Job Descriptions" in app. A. Associated and coordinated with the nursing and medical care aspects of the Loeb program are the following therapies which invariably are paid for by Loeb and carried out by personnel assigned from the respective hospital departments whose heads supervise and direct the services in question. Social service Because of the referrals from hospitals of the Loeb Center patients, social service from the hospital source will already have been involved. In addition this service will be represented on the "policy" and on the admission and disposition committees. The continuity of social care thus made possible will be the responsibility of the social service worker at Loeb. An experimental approach will be initiated whereby the social worker will work directly with patients she helps to select for this service, and she will work indirectly with the majority of patients through a consultation service to assist nurses and others in integrating appropriate social concepts into their contributions as they work directly with the patients and families. She will be the specialist who helps the nurse become a support to aid the patient relate more adequate to hospital and community life and to assist him in facing and solving social problems. An important aspect of this process will be the work with families to reduce overprotection and invalidism and to increase satisfaction and productivity. |