Interview With Natalie Germuska, RN, MSN
Note: This interview is one of an ongoing series of interviews with San Diego County hospital leaders conducted by San Diego Physician magazine. Neither San Diego Physician magazine nor the San Diego County Medical Society (SDCMS) supports or opposes any views expressed by an individual interviewed for the purposes of publication in San Diego Physician magazine.
[The following interview took place on February 5, 2009.]
San Diego Physician: Tell us how you came to Kindred Hospital. Out front it looks as if you’re celebrating your 15th anniversary, so it’s a young hospital.
Natalie Germuska: Actually, Kindred has been around for a long time. We’re the only Kindred hospital in San Diego, but we’re part of the Southern California District, which is eight hospitals, and there are 82 Long Term Acute Care (LTAC) Hospitals nationwide. Kindred is a large company. We are part of the hospital division, we have a nursing home division with approximately 230 nursing homes, and then we have the Peoplefirst rehabilitation division. In that division we contract out rehabilitation services (PT,OT,SLP) to other facilities. Kindred Hospital San Diego is the southern most hospital.
SDP: Do you know when Kindred itself was started?
Germuska: Kindred began more than 20 years ago and Kindred Hospital San Diego opened in 1992. Since 2005 we have made some changes. This hospital used to run a census of 68 ventilator-dependent patients consistently. Over the years, we added services to support not only ventilator dependent patients but those with extensive wounds, post-surgery with complications, patients who have septicemia, TPN, telemetry monitoring requirements. Overall, we consider ourselves a treatment center for those patients who continue to require daily physician visits after full diagnostic work up is completed at the Short Term Acute Hospital. Our average length of stay is approximately 32 days. Medicare requires LTACs to have at least a 25 day length of stay for reimbursement.
I believe people think of us as a skilled nursing home or a sub-acute, but really we are an acute-care hospital, Joint Commission-accredited, Department of Health rules and regulations apply, all Title 22, Title 24. We are more of a critical care specialty hospital than a sub-acute. We have 62 beds of Med/Surg with Telemetry capability, an 8 bed ICU and 2 Operating rooms.
SDP: What brought you here?
Germuska: I’ve lived in Southern California for the last 18 years, and I actually worked at Scripps at the Encinitas Hospital for about eight of those years; I still live up in Encinitas. While at Scripps, I had the responsibility for the in-patient services including support services such as laboratory, pharmacy and respiratory. My educational background is in Critical Care nursing. I left Scripps and took a CNO position with Tenet to get experience as a member of the senior leader executive group and work in the “for-profit” arena. I worked through Tenet for a couple of years, actually starting at Garden Grove Hospital initially in Orange County, commuting there, and then moved down to Alvarado for a brief period. When I was approached about an opportunity at Kindred Hospital in San Diego, I thought it would be a great fit with my clinical background and operational experience. Critical care patients, just what I love to do. When I came to Kindred, I actually came here as the Chief Clinical Officer, overseeing the Hospital Operations. It was a hybrid position of CNO and COO. Right after I came on board, the CEO who was here moved back to Texas to be closer to family, so after a couple months here I became the CEO. In this role, I have the ability to make decisions operationally as well as work closely with the physicians and community. As an LTAC we receive all of our referrals through relationships with the staff and physicians at the surrounding hospitals. A big part of my current role is educating physicians and the community about our services, talking to case managers, getting out to the skilled nursing facilities because we’re an option for the transfer of a sicker patient for them. Approximately half of my time is spent outside of the hospital developing relationships and sharing information regarding Kindred Hospital San Diego.
SDP: So your own education is clinical.
Germuska: Yes, I’m an MSN, RN.
SDP: How many patients, staff, physicians do you have here?
Germuska: Two hundred staff, that’s roughly what we’re running right now, and about 100 physicians on staff, it’s mostly internal medicine, pulmonary coverage, but I do have ENT, plastic surgery, vascular surgery, general surgery, anesthesia. For a small hospital we actually have all the specialties on board right now, and that was something that has evolved over the last three years. To actually build our census, in talking with the community, short-term acute care facilities and physicians, we realized that we need to provide the gamut of services. By having specialists on staff we are able to provide a higher level of care than the sub acute setting and expand the types of patients we admit. I believe that specialist coverage has been problematic with long-term acute cares because we’re small; physicians don’t want to extend their practice to us. So it’s really important to get out to the community and show our outcomes, what we can actually do for patients and pulling those types of physicians in to help us care for them. We’ve been very successful with that.
SDP: How many patients?
Germuska: We run a census in the 50s, and we have 70 licensed beds, 68 operational. We are busier in the winter months as this is when the cold and flu season hits and there are many more medically complex patients requiring prolonged weaning from mechanical ventilation. At any given time 50% of our census is patient weaning from a ventilator. We also have many patients with infections, so a lot of them need to be in private rooms, about half our rooms are private, the others are semi-private, which sometimes limits admission capability. We would like to increase our census to 60 on a consistent basis.
SDP: So you don’t contract with one medical group?
Germuska: No, we’re a melting pot. Our medical director is a Sharp physician; he’s a triple-boarded pulmonologist, Dr. Davies Wong, from the Sharp Chest Medicine Group. And then we have Dr. Sam Clark, again triple board certified in Internal Medicine, Critical Care and Pulmonary Medicine, who oversees our Critical Care Unit and Night Physician Program, and he’s actually a Sharp and Scripps physician. We also have physicians with primary practices at Scripps Mercy, Paradise Valley Hospital, Alvarado and Grossmont on staff. They all consult and cover for each other. We are the great melting pot of San Diego. They share ideas and we are able to take best practices from the San Diego area and incorporate them into protocols and daily practice. Our ventilator weaning protocols were influenced by pulmonologists from Scripps, Sharp, Alvarado and UCSD. So we have the best of all minds working on care initiatives at Kindred. I believe our positive patient outcomes speak to these initiatives.
SDP: What’s the hospital’s mission or vision, or both?
Germuska: I think we’re like everybody else. We want to be the provider of premier healthcare services specific to Long Term Acute Care. We want to be the provider of choice for LTAC service, and we want to be the employer of choice for the nurses and staff that want to work in this level of care. It’s a distinct level of care. There’s a lot more family interaction, patient care conferences, interdisciplinary rounds. We have patients for a month, not seven days. You really get to know your patients and their families. So I think we look for those types of staff and physicians. Our mission statement includes clauses such as: providing cost-effective care, high-quality care, and we want to do it in a dignified environment. I believe that’s the key word, the “dignified” environment for the patients and the family.
SDP: Are there any other facilities in the county that do long-term acute care?
Germuska: There are. They are Continental Rehabilitation; although the name is deceiving, they are actually licensed as a long-term acute care facility. They were recently purchased by Vibra, which is a younger company coming in to the LTAC market. Continental provides similar care but does not have the ICU level at this time. Then, there’s Promise, which took over UCMC in 2006.They also have other hospitals in the Coastal areas. But we’re the largest provider of LTAC services with over 80 Hospitals nationwide, we have been providing this level of care for the longest.
SDP: Describe your patients and the insurance mix you have here.
Germuska: Medi-Cal doesn’t observe this level of care, and that’s been an ongoing issue with all the LTACs, specifically this region. LTAC is an acute-care hospital level but with Medicare we fall under a different payment structure. There’s a long-term acute care DRG, so when a patient comes from a short-term acute, if they meet our admission criteria (Interqual), Medicare will pay us under the different payment structure. About 85% of our patients are Medicare, 15% are some type of managed care payer (Blue Cross, Blue Shield, Healthnet, Aetna, Cigna), we have over 20 different contracts. In terms of outcomes, about 25 percent of our patients go home from here. The rest either go to a SNF-level of care or rehab level of care prior to going home, and then we have a certain amount who actually expire with us.
SDP: But you don’t have a lot of Medi-Cal?
Germuska: We have a few when we take Medicare patients and they don’t progress and for whatever reason can’t go to a lower level of care, they will flip Medi-cal with us, they’ll actually transfer to a Medi-Cal status. We then go through the process of submitting TARs to Medi-Cal but many times these are denied due to the level of care.
SDP: So mostly Medicare?
Germuska: Mostly Medicare, about 80 to 85 percent, and the rest are managed care, about 15 to 20 percent. We do see patients who are younger, and that’s where we get some of our managed care like a Blue Cross, Blue Shield, Healthnet and Cigna patients. A patient who’s been working who has a traumatic injury, a motor vehicle accident, something like that, ends up on a trauma service, we take those patients, quadriplegic, paraplegic, head injury. We focus on readying those patients for rehabilitation, getting them ready to tolerate 3 hours of rehab per day. Once they are able to tolerate two and a halfhours, then we’ll start asking the acute rehabs to come in and look at them for further rehab care. We handle all of their other medical issues in the interim.
SDP: You must have an amazing group of patients. I’m sure you’ve got some incredible stories of struggle and overcoming.
Germuska: Yes, we’ve sent patients to different states for intensive rehab services if their families are there after medical problems are stabilized. Sometimes we get people that are vacationing here and get into motor vehicle accidents and end up going to different states. We just had a patient who was a religious leader in India and ended up here with his family and had thousands of followers in India who hadn’t heard his voice in two months because he was on a ventilator. He came here, we immediately put him on a Passy Muir Valve. He actually called India and talked to his followers. We eventually ended up getting him decanulated, which means we took his trach out. He was able to breathe on his own, and he flew back to India and went home.
SDP: What challenges do you face at Kindred?
Germuska: I think around case management, how do you manage that patient through the process of care in the time that you’re given related to reimbursement? Even though we’re allowed a lot more time than the short-term acute, where they’re given a 10 to 14-day length of stay for their intensive care patients, we’re given maybe 30 days, but still that’s a short amount of time because we’re taking a high acuity patient. Certainly reimbursement issues, and the Medi-Cal issue. When you have non-funded patients it is difficult to maintain services. I think staffing issues are the same. We need a high skill level nurse. We need the ACLS-certified ICU nurse. We need the telemetry nurse. They’re hard to come by. So I think those issues are similar. And then I think we have a whole other different issue in terms of educating the community on what we do. I think we battle that every day. What is a long-term acute care hospital? People think we’re a skilled nursing facility/sub-acute. We rely on those referrals from people that are knowledgeable in the community to send us the right patient so it’s a win-win. It’s a win for the patient; it’s a win for the Hospital. I think this article will help us, and all the work that we do with the American Lung Association, with the community, the Better Business Bureau, Chamber of Commerce, we’re in all those organizations to try to tell our story. What is the value of a long-term acute care facility? Highly specialized critical care, a bridge to lower levels of care.
SDP: So you’re doing OK?
Germuska: The last couple of years have been years of re-building, we had some challenges early in 2000. We had some changes in leadership at that time. We weren’t out in the community as much, and I think the last three years we have been more involved. I’m a member now of the San Diego Hospital Association, on the board of directors, so I can give input from my perspective on the issues affecting all of the hospitals. They know more about what we do. I think it just is a continuous educational effort on our part, and of course we need to have excellent patient outcomes because if we don’t, the referrals will stop coming. But we’ve actually been able to double the census in the last three years.
SDP: How long have you been here?
Germuska: Three years.
SDP: Congratulations! So, tell our readers about the services that you provide and how they can access those services.
Germuska: The way that we educate the community and the physicians about the services that we have is through one-on-one meetings and group presentations. We have a team of clinical liaisons; they have different clinical backgrounds, either nurses or respiratory therapists, and myself, we go out and promote our services. We’re active in the Chamber of Commrece, members of the Better Business Bureau, active in our community, Lung and Heart Associations, and nursing groups. Educating nurses is one way that we can gain access to physicians and influence referrals of patients. We meet with medical directors of physician organizations, managed care payers and the Hospitals. Those folks talk with their colleagues and link us to physicians that may have patients appropriate for this level of care.
Overall, we offer a full range of clinical services for the medically complex patient including intensive care, rehabilitation and telemetry/cardiac monitoring. We have interdisciplinary team rounds. Weekly care conferences that families attend every week so they are updated on the plan of care for their loved ones, they feel more involved. As I mentioned earlier we have accessibility to many specialists and 2 licensed operating rooms, digital radiology services and floro capability. We’re getting a new multi-site CT scanner onsite in April. There are a lot of great things that are happening here, a lot of growth, and I want people to know that about Kindred.
And all they need to do is give us a call if they want to know more. We’ll link them to our Director of Marketing, one of our clinical liaisons, or myself. We’ll come to the physician, case manager offices, give them the information they want and give them a quick overview of our outcomes. If they ever have a question about a patient they can just call the main number or one of our liaisons directly, and we’ll go out and evaluate their patient and let them know if they meet the criteria.
SDP: What’s the main number?
Germuska: It’s (619) 543-4500, and our admissions office is extension 4265, and then Gene Calvert, our admissions coordinator, will contact whomever is appropriate for patient evaluation. After hours, our hospital operator will direct the referral to the clinical liaison on call. We are available 24/7.
SDP: Anything before we end?
Germuska: In my mind I believe that we have a service that the patients and physicians need, we are an integral piece of the continuum of care, and I just think that there isn’t enough education about that piece of the continuum. We are willing to go speak to whomever, whenever to get our message out there, and we’re very proud of the work that we do. I think that that’s the most important thing.
SDP: I think for most physicians the world of long-term care is just separated from theirs.
Germuska: Yes, and I just think that they and other health care providers are only familiar with the one piece of the post acute spectrum, which is the skilled nursing/sub acute level, and we are so much more than that. We wean patients off of ventilators quicker than they do in the short-term acutes just because we have protocols and consistency with a high level of respiratory and nursing staff. We have respiratory therapists who intubate patients. Our respiratory department has earned the Quality Respiratory Care Recognition from the American Association of Respiratory Care. We also participate in national studies such as Transtracheal Augmented Ventilation (TTAV)study with Respironics. We have such highly skilled and trained staff, and I even think that the staff in the other facilities don’t realize that we actually have in our midst triple-boarded physicians, ACLS-certified nurses who have worked at Sharp and Scripps. These staff and physicians choose to work here because they have more of that relationship with the patients and families, they can actually see the patients move through the continuum of care not in a snapshot of five days but during the course of a month. Staffing ratios are also the same here as they are at the short-term acute hospitals; I believe people think we have less staff, but they’re exactly the same. I appreciate the opportunity to share my perspectives on this important piece of the healthcare continuum. I am proud to lead the Kindred San Diego organization.