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Care Right Where You Are: Treating in Place to Avoid an Emergency Department Visit or Hospitalization

      Graphical abstract

      There has never been a more important time to implement treating-in-place for skilled nursing facility residents than the ongoing COVID-19 pandemic. With emergency department (ED) and hospital beds filling with potentially contagious patients and health care staff stretched to respond to a demanding infection, managing residents within the SNF has become a priority.
      ED visits and hospitalizations are common among SNF residents, with nearly a quarter of residents returning to the hospital each year (Medicare, “Nursing Home Compare,” https://www.medicare.gov/nursinghomecompare). Hospitalizing SNF residents is costly for the health care system and risky for the individual, causing disruption, disorientation, and potential for medication errors, complications, and hospital-acquired infections as well as a likelihood of reduced functioning on return to the nursing home (J Am Geriatr Soc 2010;58;627–635). Many of these hospitalizations are potentially avoidable (Centers for Medicare & Medicaid Services, “Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents [NFI],” https://go.cms.gov/39ozyYt). But beyond having a system in place, educating long-term care residents and families that care can be provided right where they are is critical: far too many believe the ED and hospital are safer, better places for care, which can be far from the truth.

      Regulatory Guidance to Reduce Rehospitalizations

      Legislative and regulatory changes over the past decade have addressed the need to reduce potentially avoidable hospital admissions. The Affordable Care Act of 2010 established the Hospital Readmissions Reduction Program in 2013, designed to reduce payments to hospitals that had excessive 30-day readmissions for specific indications. In 2019, the 21st Century Cures Act required the Centers for Medicare & Medicaid Services to assess a hospital’s performance relative to other hospitals with a similar proportion of patients who are dually eligible for Medicare and Medicaid. The hospital payment reduction is capped at 3% (CMS, “Hospital Readmissions Reduction Program [HRRP],” https://go.cms.gov/2vZEsh9).
      Medicare’s Nursing Home Compare uses these current unplanned readmission measures for hospitals:
      • Acute myocardial infarction
      • Chronic obstructive pulmonary disease (COPD)
      • Heart failure
      • Pneumonia
      • Coronary artery bypass graft surgery
      • Elective primary total hip arthroplasty and/or total knee arthroplasty
      The Protecting Access to Medicare Act of 2014 (PAMA) established the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program. SNFs receive a 2% Medicare rate reduction and are then given the opportunity to earn back some or all of that reduction based on how well they reduce their rate of unplanned, all-cause hospital readmissions that occur within 30-days of admission to the SNF. This risk-adjusted SNF rehospitalization measure applies only to Medicare beneficiaries enrolled in original Medicare.
      In 2012, CMS began implementing the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents (NFI). This voluntary program includes clinical and education components and a payment model that offers special Medicare billing codes to participating SNFs and practitioners (physicians, advanced practice registered nurses, and physician assistants). The billing codes act as a financial incentive for providing care in-house to eligible residents enrolled in Medicare fee-for-service (FFS), rather than transferring them to hospitals for treatment. To receive the financial incentive, facility staff and practitioners assess, diagnose, certify, and treat higher acuity, long-stay residents who may have one of six qualifying conditions (RTI International, “Evaluation of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents—Payment Reform,” Third Annual Report, December 2019; https://bit.ly/3bCnC7e).
      Six conditions are evaluated in the NFI:
      • Chronic obstructive pulmonary disease or asthma
      • Congestive heart failure
      • Fluid/electrolyte disorder or dehydration
      • Pneumonia
      • Skin infection
      • Urinary tract infection
      The conditions that make up the HRRP and the NFI differ slightly. The HRRP conditions reflect potentially avoidable hospital readmissions in the ambulatory adult population. The NHI conditions reflect those that are more common among SNF residents.

      Interdisciplinary Approach to Reducing SNF Rehospitalizations

      The most common quality improvement opportunities for SNFs to reduce avoidable hospitalization (Innov Aging 2019;2:igy017) include:
      • Having appropriate resources available (a factor cited in 45% of transfers associated with any of the six diagnoses).
      • Improving communication among stakeholders (a factor cited in 48% of transfers).
      • Detecting changes in status earlier.
      • Understanding patient preferences or a palliative care plan better.
      In addition to improving on these opportunities, SNFs should also seek to optimize the management of the six conditions likely to result in hospitalizations. To do this, an interdisciplinary team (IDT), including at minimum all the members of the pharmacy and therapeutics committee, should review nationally accepted guidelines for common conditions that often require a visit to the ED and/or hospital admission. Using the conditions identified in the NFI is a good place to start.
      The IDT should customize treatment protocols based on national guidelines adjusted to fit the clinical staff, equipment, and resources available in the SNF setting. Once a treatment protocol is approved, the IDT must develop a process to educate prescribers, clinical care staff, and direct resident-care staff on the specific steps for day-to-day management as well as exacerbation management for each targeted condition. Input from hospitalists or specialists may be valuable to ensure the SNF treatment protocols compliment the hospital discharge strategies in your area.
      It is also important that the IDT work with the LTC pharmacy provider to verify access to the most cost-effective treatment options required for the protocol. Once implemented, the SNF treatment protocols should be reviewed annually and updated as necessary to reflect current treatment guidelines.
      The guidelines themselves contain complete information, but selected highlights of the treatment protocols are presented here. (Note: The guidelines provided here are examples. Other guidelines exist that may be considered by the IDT in the development of protocols that are most appropriate for your facility.)

      Chronic Obstructive Pulmonary Disease (COPD)

      Guidelines:
      • Global Initiative for Chronic Obstructive Lung Disease (“Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, 2020 Report,” 2020; https://bit.ly/3bxbDaR)
      • AMDA – The Society for Post-Acute and Long-Term Care Medicine (“COPD Management in the Post-Acute and Long-Term Care Setting,” Clinical Practice Guideline, 2016; https://bit.ly/2wLeXQO)
      Key Maintenance Management Concepts: Treatment should be tailored based on the level of symptoms and risk for exacerbation. Inhaler technique should be evaluated, and if resident is unable to comply with required inspiratory capacity and inhaler activation, consider changing the inhalation device. Nebulization may be appropriate for residents who have physical or cognitive deficits. Long-acting bronchodilators are preferred over maintenance therapy with short-acting agents. Inhaled bronchodilators are preferred over oral bronchodilators. Theophylline is not recommended unless other long-term treatment bronchodilators are not available. Long-term monotherapy with an oral or inhaled corticosteroid (ICS) is not recommended unless there is a history of exacerbations. Long-term oxygen therapy is indicated when PaO2 <7.3 kPa or SaO2 ≤ 88% twice over a three-week period.
      Key Exacerbation Management Concepts: For residents who have an exacerbation, short-acting beta-agonist bronchodilators (SABA) are recommended. If the exacerbation occurs while the patient is receiving long-acting bronchodilator monotherapy, consider escalating to combination therapy with a long-acting beta-agonist (LABA) and long-acting antimuscarinic (LAMA) or LABA/ICS combination. Reevaluate the patient’s ability to effectively use an inhalation device, and switch to a nebulizer if necessary.

      Heart Failure

      Guidelines:
      • American College of Cardiology/American Heart Association (J Am Coll Cardiol 2017;70:776–803)
      • European Society of Cardiology (“Acute and Chronic Heart Failure Guidelines,” ESC Clinical Practice Guidelines, 2016; https://bit.ly/2UnxawP)
      • AMDA (“Heart Failure in the Post-Acute and Long-Term Care Setting,” Clinical Practice Guideline, 2015; https://bit.ly/33Pr8Is)
      Key Management Concepts: Systolic and diastolic blood pressure should be controlled. The use of beta-blocking agents, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) in patients with hypertension is reasonable to control blood pressure. Diuretics should be used for relief of symptoms due to volume overload. ACE inhibitors reduce morbidity and mortality in heart failure with reduced ejection fraction. ARBs were developed with the rationale that angiotensin II production continues in the presence of ACE inhibition, driven through alternative enzyme pathways. ARBs do not inhibit kininase and are associated with a much lower incidence of cough and angioedema than ACE inhibitors; however, like ACE inhibitors, ARBs should be given with caution to patients with low systemic blood pressure, renal insufficiency, or elevated serum potassium. Long-term therapy with ARBs has been shown to reduce morbidity and mortality, especially in ACE inhibitor–intolerant patients. An ARNI — an ARB combined with a neprilysin-inhibitor, an enzyme that degrades natriuretic peptides, bradykinin, adrenomedullin, and other vasoactive peptides — reduced the composite end point of cardiovascular death or SNF hospitalization significantly by 20% (Circulation 2016;133(11):1115–1124).

      Fluid/Electrolyte Disorder and Dehydration

      Guideline: AMDA (“Dehydration and Fluid Maintenance in the Long-Term Care Setting,” Clinical Practice Guideline, 2009; https://bit.ly/2UJ7M3E)
      Key Management Concepts: In the elderly, most fluid/electrolyte imbalances present initially with nonspecific symptoms such as lethargy, confusion, or a decline in function that may be abrupt. Adverse drug reactions, acute illnesses, and medical complications may cause or exacerbate the same nonspecific symptoms. The appearance of more specific physical symptoms suggestive of advanced dehydration (e.g., dry mucous membranes, sunken eyes, hypotension) may be delayed.
      • Identify possible treatments for the conditions that may be affecting fluid/electrolyte balance or causing dehydration, such as pneumonia or heart failure causing symptoms of lethargy and confusion that have resulted in decreased fluid.
      • Stop or reduce the dosage of the antibiotics that has caused diarrhea, which has led to excessive fluid loss.
      • Stop or reduce the dosage of diuretics that has caused excessive diuresis and/or the ACE inhibitors that may have worsened the patient’s sodium imbalance after the diuretics caused excessive sodium loss.
      • Packaged oral rehydration solutions are effective for stable residents who can drink. To accommodate absorption characteristics, replace approximately half of a fluid deficit within the first 24 hours. Replace the remaining deficit within the next 48 to 72 hours. Residents who are unstable due to dehydration will generally require intravenous hydration.

      Pneumonia

      Guidelines:
      • American Thoracic Society/Infectious Disease Society of America (ATS/IDSA) (Am J Respir Crit Care Med 2019;200:e45–e67)
      • Centers for Disease Control and Prevention (Management and Prevention Guidelines: Community-Acquired and Healthcare-Associated Pneumonia; https://bit.ly/2UFxVQR)
      • Nursing Home – Associated Pneumonia, Part I: Diagnosis (J Am Med Dir Assoc 2020;21(3):308–314)
      Key Management Concepts: The most common cause of pneumonia in adults older than 30 is a bacterial infection, and the different types of pneumonia include:
      • Community acquired
      • Hospital acquired
      • Ventilator associated
      • Pneumonia in immunocompromised patients (i.e., HIV)
      For suspected community-acquired pneumonia (CAP), sputum cultures and blood cultures are only recommended for patients with severe disease and inpatients empirically treated for methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa. CAP can usually be treated empirically with antibiotics. A macrolide antibiotic is conditionally recommended based on resistance levels. A beta-lactam/macrolide combination has stronger evidence. Corticosteroids are not recommended unless the patient develops refractory septic shock.
      Aspiration pneumonitis and pneumonia are common in LTC residents, especially those with a swallowing disorder. Supportive care and oxygen may be necessary, and the treatment protocol should include reassessment of the patient after two to three days to determine whether the antibiotics are appropriate (per sputum culture) or need to be changed to a more effective agent.

      Skin Infections

      Guidelines:
      Infectious Diseases Society of America (Clin Infect Dis 2014;59:e10–e52)
      • AMDA (“Pressure Ulcers and Other Wounds in the Post-Acute and Long-Term Care Setting,” Clinical Practice Guideline, 2017; https://bit.ly/2QOK2Ki)
      Key Management Concepts: Residents with nonpurulent skin and skin structure infections (SSTIs) should receive antibiotic treatment with one of the following: penicillin VK, cephalosporin, dicloxacillin, or clindamycin. The treatment depends on tolerability and the facility’s antibiograms, if available.
      • Mild infection: provide oral antibiotics
      • Moderate infection: provide intravenous antibiotics
      • Severe infection: rule out necrotizing process. Treat with empiric vancomycin plus piperacillin/tazobactam. Once culture and sensitivity results are available, the treatment should be selected based on sensitivity of the organism.
      Residents with purulent SSTIs should have incision and drainage of the wound with culture and sensitivity testing. Empiric treatment can be given based on resident tolerability and facility antibiograms, if available:
      • Moderate purulent infections: trimethoprim/sulfamethoxazole or doxycycline
      • Severe purulent infections: one of the following — vancomycin, daptomycin, linezolid, telavancin, or ceftaroline
      • Once culture and sensitivity results are available, select the treatment based on sensitivity of the organism

      Urinary Tract Infections

      Guidelines:
      Key Management Concepts: A diagnosis of urinary tract infection (UTI) requires a positive urine culture. Clinicians should use a first-line therapy such as nitrofurantoin, trimethoprim/sulfamethoxazole, or fosfomycin, depending on the local antibiogram. Treatment should be for as short a duration as reasonable, generally no longer than seven days. Posttreatment urinalysis to test the cure is not recommended. If UTI symptoms persist, a repeat urine culture is recommended to guide further management.

      Putting It Into Practice

      Keep in mind that guidelines exist to provide proven concepts for treatment, but they are not inflexible. Guidelines may need to be adjusted to fit specific patient populations or facility capabilities. Clinical judgement and individual patient characteristics are also guiding principles and often must take precedence when treating our frail, geriatric SNF residents.
      To facilitate adoption of treatment protocols, start by choosing one common condition that will be easiest for your existing staff and capabilities to manage. Once the protocol is developed and approved, consider rolling it out in conjunction with popular disease-awareness campaigns. For instance, roll out your COPD treatment protocol during November, which is National COPD Awareness Month, or roll out your heart failure protocol during February, which is National Heart Month. Communication, education, and motivation are the keys to a successful strategy for reducing avoidable ED visits and hospitalizations.
      Dr. Manzi is a clinical advisor for CVS/Caremark. Any opinions in this article are that of the author and not of CVS / Caremark. Dr. Saffel is the president and CEO of PharmaCare Strategies. She has practiced in the LTC setting for over 40 years.