Reducing Unnecessary Hospitalizations of Nursing Home Residents

FAU Professor’s Commentary on Reducing Unnecessary Hospitalizations of Nursing Home Residents Published in The New England Journal of Medicine

Newswise — It’s an all too common scenario in U.S. nursing homes – a 90-year-old resident with moderately advanced Alzheimer’s disease, congestive heart failure with severe left-ventricular dysfunction and chronic pain from degenerative joint disease develops a nonproductive cough and a fever of 100.4 degrees. The night nurse calls the on-call physician who is unfamiliar with the patient and is instructed to send the patient to the emergency room. In the ER, the patient is found to have normal vital signs except for the low-grade fever and a possible infiltrate on the chest x-ray. The patient is admitted to the hospital and treated with intravenous fluids and antibiotics. On the second night, the patient becomes confused and agitated, climbs out of bed and falls, fracturing a hip. One week later, the patient is discharged back to the nursing home with coverage under the Medicare Part A benefit. This episode results in approximately $10,000 in Medicare expenditures, and discomfort and disability for the patient.

There are more than 1.6 million Americans living in nursing homes, and these types of hospitalizations are common. Hospitalizations of frail nursing home residents can result in higher costs, complications and death. According to the “Revolving Door of Rehospitalization from Skilled Nursing Facilities,” a paper published in the January 2010 issue of Health Affairs, 23.5 percent of Medicare beneficiaries discharged from the hospital to a skilled nursing facility were readmitted to the hospital within 30 days at a cost to Medicare of $4.34 billion in 2006. These rehospitalizations are frequent and costly. Research suggests that a substantial amount of these hospitalizations may be preventable. “There is an alternative to this scenario,” said Joseph G. Ouslander, M.D., senior associate dean of geriatrics in the Charles E. Schmidt College of Medicine at Florida Atlantic University and first author of the article titled “Reducing Unnecessary Hospitalizations of Nursing Home Residents,” in the current issue of The New England Journal of Medicine. “By using a standardized protocol and working with an on-call nurse practitioner who visits the nursing home daily, the patient can be treated in the nursing home without any complications and only costing Medicare about $200.”

Using such care in nursing homes nationwide could improve care, reduce complications from hospitalizations, and avoid hundreds of millions of dollars in Medicare expenditures annually.

Ouslander and his co-author Robert A. Berenson, M.D., senior fellow at the Urban Institute in Washington, D.C., explain that although many nursing home residents could be cared for safely and effectively without being admitted to the hospital, the causes for preventable hospitalizations in this population are complex.

They explain that one of the fundamental problems with hospitalizations of this population is not clinical. Rather, it is financial and stems from a misalignment of Medicare and Medicaid. State Medicaid programs do not benefit from savings that Medicare accrues from prevented hospitalizations of nursing home residents, even though the nursing home incurs expenses when managing changes in condition without hospital transfer. In addition, nursing homes have a financial incentive to hospitalize residents who have Medicaid coverage, because after a three-day inpatient stay, the resident may qualify for Medicare Part A payment for post-acute care in the nursing home at three to four times the daily rate paid by Medicaid.

“Nursing homes, like other healthcare providers will respond to financial and regulatory carrots and sticks,” said Ouslander. “There are financial models available that provide incentives to reduce hospitalizations of frail and elderly people.”

The authors also point out that not all nursing homes have the infrastructure to undertake more acute care, and it is imperative to recognize challenges and limitations. For example, because of financial constraints and shortage of health care professionals trained in geriatrics and long-term care, not all nursing homes have the capacity to safely evaluate and manage changes in the condition of the clinically complex nursing home population. Interventions must therefore be designed for nursing homes with the resources and leadership commitment to undertake more acute care.

Interventions to Reduce Acute Care Transfers (INTERACT) is one such program that shows promise and provides the necessary tools to enhance the nursing home’s ability to identify, evaluate and manage conditions before they become serious enough to necessitate a hospital transfer. Developed by Ouslander and his collaborators in FAU’s Christine E. Lynn College of Nursing, INTERACT was implemented at 25 community-based nursing homes in Florida, Massachusetts and New York over a six-month period and resulted in a 17 percent reduction in hospital admissions among the residents. The reduction was even greater in homes that were more engaged in implementing the INTERACT intervention.

“If implemented widely, the program could result in fewer complications, lower morbidity from hospitalizations and reductions in Medicare costs. Some of the savings could be used to support improved care in U.S. nursing homes,” said Ouslander.

In conclusion, the authors emphasize that improving care and reducing complications in nursing homes will require multifaceted strategies to address the current incentives for hospitalization and a team effort among health care funders, regulators, health care professionals, nursing homes and hospitals.

– FAU –

About Florida Atlantic University:Florida Atlantic University, established in 1961, officially opened its doors in 1964 as the fifth public university in Florida. In commemoration of its origin, FAU is celebrating its 50th anniversary throughout 2011. Today, the University serves more than 29,000 undergraduate and graduate students on seven campuses and sites. FAU’s world-class teaching and research faculty serves students through 10 colleges: the Dorothy F. Schmidt College of Arts and Letters, the College of Business, the College for Design and Social Inquiry, the College of Education, the College of Engineering and Computer Science, the Graduate College, the Harriet L. Wilkes Honors College, the Charles E. Schmidt College of Medicine, the Christine E. Lynn College of Nursing and the Charles E. Schmidt College of Science. FAU is ranked as a High Research Activity institution by the Carnegie Foundation for the Advancement of Teaching. For more information, visit www.fau.edu.