As many as half of hospitalizations of nursing home residents might be avoidable, causing not only unnecessary suffering among those residents, but also as much as $2.3 billion in unnecessary health care spending each year in the United State.
Those are key conclusions from “Reducing Hospitalizations of Nursing Home Residents: A Center for Medicare and Medicaid Services Special Study,” led by Joseph G. Ouslander, MD, CMD, associate dean for geriatric programs at the Charles E. Schmidt College of Biomedical Science at Florida Atlantic University, Boca Raton.
In an interview, a member of the expert panel that contributed to the study, Jacqueline Vance, RN, CDONA/LTC, said that the research focused on Georgia nursing home residents with the purpose of finding factors that contributed to potentially avoidable hospitalizations, as well as developing and testing strategies to reduce them.
Over a 15-month period in 2005-2006, the average hospitalization rate from nursing homes for the state of Georgia was 1.62 per 1,000 nursing home resident-days. The average number of hospitalizations per nursing home was 104. The researchers extrapolated these data to 377 nursing homes in Georgia, indicating 31,666 hospitalizations of nursing homes' residents annually.
The 10 nursing homes with the highest hospitalization rates in the study had more certified beds, a higher proportion of residents on Medicaid, fewer residents who were white, fewer residents with do-not-resuscitate orders and living wills, and more residents with pressure ulcers (stage 2 or higher) than the 10 homes with the lowest hospitalization rate. The high-hospitalization group also had substantially less availability of medical directors, primary care physicians, and nurse practitioners or physician assistants. The low-hospitalization homes reported greater proportions of residents with advance directives and DNR orders.
Ms. Vance identified the chief factors in avoiding unnecessary hospitalizations: the availability of physicians, nurse practitioners, and trained nurses in the nursing home; those professionals' and others' skills in recognizing when a resident is having an acute change of condition (“going back to the basics of critical thinking and being a detective,” she said); and being able to start and maintain IVs in the nursing home.
“In the study, so many people were sent [to hospitals] just because nobody in the [nursing] facility could execute an IV,” said Ms. Vance, the director of clinical affairs and industry relations for AMDA in Columbia, Md.
She said that other factors contributing to hospitalizations were a lack of in-house diagnostic and support services, such as use of a portable x-ray machine, and access to emergency medications. “Having a well-stocked emergency drug box is practical and important so if [residents' need medication] they don't have to wait for it, especially at night and on weekends,” Ms. Vance said.
She and the other expert panelists concluded that 75% of hospitalizations among the 10 high-hospitalization nursing homes were definitely or probably avoidable, compared with 59% of hospitalizations among the low-hospitalization nursing homes.
The researchers went on to estimate that hospitalization of U.S. nursing home residents cost $4.5 billion in health care dollars each year. That figure is based on the assumption that 450,000 nursing home residents are hospitalized each year and that each episode costs $10,000. The researchers based their calculation of $2.3 billion in unnecessary health care costs on the assumption that 50% of hospitalizations are avoidable. That money could be invested in improving nursing home care, said the authors.
“So many times, hospital transfers are made because the practitioners get frustrated from lack of information and they don't know what to do,” Ms. Vance said. “It's not only recognizing that something is happening; it's also communicating properly and in enough detail what's going on to the practitioner. These things can be done,” she maintained. “This is not pie-in-the-sky.”
She added that with this in mind, AMDA developed “Protocols for Practitioner Notification,” a guide for nursing staff to report changes of condition. The document is available at www.amda.com/resources/index.cfm.
The CMS-sponsored study tested strategies to reduce the rate of unnecessary hospitalizations, including ensuring an exam by the attending practitioner within 24 hours of a noted change of condition, increasing registered nurses on staff, and gaining the ability to complete lab tests within 3 hours of problem identification. Such approaches are currently being refined and evaluated in a Commonwealth Fund-sponsored study under way at nursing homes in Florida, New York, and Massachusetts.
Dr. Ouslander said that nursing homes will require additional infrastructure support to reduce the rate of unnecessary hospitalization of residents. “Otherwise, care could get worse,” he said in an interview. “If nursing homes try to keep sicker residents in the facility and don't have the infrastructure and staff to [meet their needs], the hospitalization could be unnecessarily delayed.”
He also emphasized the amount of medically futile care provided to nursing home residents who are clearly terminally ill, such as repeated hospitalization for aspiration pneumonia in end-of-life situations. “Advance care planning in nursing homes must be improved,” he said.
Liability issues also come into play. “I think that nursing homes and physicians who are medical directors and primary care physicians are legitimately concerned about liability” because they manage very sick people, he said. “There has to be some tort reform, because this is a real potential barrier to managing people in the nursing home.”
Dr. Ouslander said that until such reform occurs, he believes that using care protocols and guidelines developed by AMDA and tools such as those available at the QualityNet Web site (www.qualitynet.org), and clearly documenting the assessments and management plans that result from those tools' use, will improve care and protect providers from many of their liability concerns.
Information about the CMS study can be viewed at the QualityNet Web site: www.qualitynet.org/dcs/ContentServer?c=MQTools&pagename=Medqic%2FMQTools%2FToolTemplate&cid=1211554364427.
Doug Brunk is with the San Diego bureau of Elsevier Global Medical News.
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