The origin of sub-acute care

The Origin of Sub-Acute Care

The Greenery Rehabilitation and Skilled Nursing Center in Brighton, Massachusetts provided some of the most complex care ever in a skilled nursing facility. It opened in 1971 as the Greeney Nursing Home. George Ferencik became the administrator in 1972 and was associated with the facility until 1993. It was under his leadership that Greenery developed its world-famous head injury rehabilitation programs. George identified the need to serve a type of patient being discharged from local hospitals who required a level of care not found in the typical nursing home of that era. These patients required sophisticated nursing, recuperative and rehabilitative services not available outside of the acute hospital setting.

In 1972, preceding the establishment of the three major rehabilitation hospitals that today serve the greater Boston area, George sought certification for a forty-bed unit for participation in the Medicare program. The following year that unit admitted more than four hundred patients, successfully discharging 398 to their homes. The rehabilitation experience, gained primarily in the care of stroke and orthopedic patients, led Greenery to develop specialty services for neurologically impaired patients. Responding to the demands of hospital discharge planners, Greenery became the treatment facility of choice for patients who needed brain injury rehabilitation. By 1978, Greenery exclusively admitted patients who had suffered traumatic brain injury. The vast majority of these patients were young adults who had suffered traumatic brain injuries often as a result of motor vehicle accidents. The average length of stay was 3 to 5 years. Very few patients were expected to live independently or be competitively employed. Greenery became one of the early sponsors of the National Head Injury Foundation, now known as the Brain Injury Association of America. This foundation was instrumental in developing alternative living and employment arrangements for young people who were brain injured.

The Greenery provided intensive rehabilitation and skilled nursing services staffed with its own PT, OT, speech, and respiratory therapists. To ensure a true interdisciplinary process, the facility established a case management department. This department, staffed by non-direct care nursing and rehabilitation professionals, coordinated the services delivered to each patient in a way that responded to the needs of the patient, the family, and the third-party payer. This was years ahead of the concept that we today know as managed care.

By 1980, the Greenery Rehabilitation and Skilled Nursing Center had developed an international reputation for the care of head-injured patients. The facility had specialized units caring for patients at various levels of cognitive awareness. Greenery was the largest program of its kind in the world with two 40-bed units caring for coma patients, one unit for higher-level rehabilitation patients, and specialty units for behavioral and cognitive rehabilitation as well as ventilator support services. Greenery initiated innovative financing for the payers of catastrophic care by developing all-inclusive per diem rates. This simplified the claims management for the payer agencies while allowing clinicians to provide services to each patient without regard to reimbursement.

Greenery was first accredited by the JCAHO in 1976. In 1981 Greenery became accredited by the Commission for the Accreditation of Rehabilitation Facilities (CARF) under the comprehensive inpatient rehabilitation standards. Greenery was the first skilled nursing facility to be accredited under these standards, which were written for rehabilitation hospitals. Later, CARF, recognizing alternative treatment sites, developed separate standards for skilled nursing facility-based subacute units.

Consider these additional examples of complexity and uniqueness in place before 1984 many of which are now widespread practice:

• The first comprehensive inpatient brain injury rehabilitation program in a skilled nursing center.

• Patients from forty-four states and four foreign countries, Greenery developed an international reputation for the care of head-injured patients

• Over 110 patients on tube feedings.

• A ventilator unit with twelve patients.

• Twenty-eight physical therapists, twenty-six occupational therapists, sixteen speech therapists, and twelve respiratory therapists on staff in the 201-bed SNF.

• The first to utilize an all-inclusive per diem for ease of billing to insurance companies.

• First use of clinical evaluators to screen patients off-site to ensure accuracy of clinical information before admission.

• The first to utilize a dedicated case management department of non-treating clinicians.

• The first SNF to be accredited by Commission for the Accreditation of Rehabilitation Facilities (CARF) under the comprehensive inpatient rehabilitation standards which were written for rehabilitation hospitals. Today, CARF, recognizing alternative treatment sites, developed separate standards for skilled nursing facility-based subacute units.

• The first physiatrist-directed rehabilitation program with fellows and residents rotating through the program.

In 1986, Greenery became a public company, with aim of replicating the head injury rehabilitation program. George Ferencik became the president of the company. The company eventually grew to 22 SNF-based head injury rehab programs nationwide. Another rehab company later acquired Greenery. The original facility in Brighton, MA discharged its last patient and closed its doors at the end of November 2001.

Over the 30+ years of operation at the original location and subsequent expansion facilities around the country, countless nurses, rehabilitation professionals and administrators started their careers at Greenery. These professionals continue providing high-quality care today.