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, resulting in $10,000 in Medicare expenditures, and discomfort and disability for the patient.
More than 1.6 million Americans live in nursing homes, and these types of hospitalizations are common. According to a January 2010 article in 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.
“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 “Reducing Unnecessary Hospitalizations of Nursing Home Residents,” published in 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 the causes for preventable hospitalizations in this population are complex.
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, and financial models are available to provide incentives to reduce hospitalizations,” said Ouslander.
However, not all nursing homes have the infrastructure to undertake more acute care, and it is imperative to recognize challenges and limitations. 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.
Improving care and reducing complications in nursing homes will require multifaceted strategies and a team effort among health care funders, regulators, health care professionals, nursing homes and hospitals.
