Recognizing their role in chronically high hospital readmissions, executives and clinicians at post-acute facilities are working to improve care on several fronts. Approaches include filling gaps in discharge information, re-emphasizing the fundamentals of clinical care and, in some cases, putting physicians and physician extenders on the floor in SNFs and long-term care facilities.
These substantial investments are warranted because — despite decades of efforts — preventable readmissions remain a major problem that affects both clinical and financial outcomes. About one in four hospital discharges of Medicare patients results in a readmission within 30 days, and approximately three-quarters of these rehospitalizations are avoidable.
Filling the Information Gap, Post-Discharge.
Post-acutes seeking a more complete picture of incoming patients are looking at the discharge packet as a call to action. “It’s key to have someone at the receiving institution to take in information for the patient,” says Luke Hansen, MD, an internist at Northwestern Memorial Hospital in Chicago. For example, “someone needs to make thoughtful decisions about which medications to continue and which to stop.”
“We try to anticipate what the needs of the patient will be and communicate them to all stakeholders in care,” says Ronald Shumacher, MD, chief medical officer of Evercare, a UnitedHealth Group company that manages post-acute care for patients in residential facilities or at home. “If they’re prone to pneumonia or have difficulty swallowing, we would talk to the family, primary-care provider or SNF staff to make sure they understand the probabilities of events like aspiration. It’s much easier to reduce hospital readmissions if you anticipate rather than react.”
Post-acutes can help prevent some rehospitalizations by reaching beyond compromised patients for answers, to ensure the correct information is captured. “Patients with dementia often can’t communicate effectively or make medical decisions, so we engage the family very quickly and give them accurate information on individual health-care needs,” says Dr. Shumacher.
Systematic Approaches to Clinical Care.
From the post-acute point of view, trimming rehospitalizations means re-emphasizing those basics of care and ensuring they are performed consistently. SNFs and long-term care facilities are implementing programs such as Interact, a program initially funded by the Centers for Medicare & Medicaid Services (CMS) and now operating under a grant from The Commonwealth Fund.
Interact is designed to raise the quality of care by providing tools to improve the identification, evaluation and communication of changes in post-acute patients’ health status. Interact, which stands for Interventions to Reduce Acute Care Transfers, concentrates on getting bedside health workers to recognize and act on warning signs for the diseases that are the most common causes of rehospitalization, including heart failure, pneumonia and chronic obstructive pulmonary disease.
“We’re putting into place Interact, which says that if certain symptoms appear in a patient, start on these measures to prevent a hospital admission,” says Susan Fry, RN, senior vice president for health and wellness at Presbyterian Manors of Mid-America, which offers a continuum of care to residents at 17 locations in Kansas and Missouri.
Noticing the warning signs of a potential acute episode is often within the scope of practice of most health-care workers in a nursing home, including those below the level of RN. “If a patient is not eating or drinking or alert as usual, we want the CNA to notify a nurse immediately,” says Eva Fabian, vice president of clinical services at Workmen’s Circle MultiCare Center in New York, which also has implemented Interact. The Interact program supplies information about when clinicians should consider ordering IV hydration, blood work, an antibiotic or whatever tests or treatment might be appropriate to the patient’s condition.
As basic as much of Interact is, early implementations have demonstrated that the program can prevent many unnecessary hospital readmissions. “Interact has significantly improved our rate of rehospitalization,” says Fabian. “Before it was about 40 percent; now it’s down to 10 or 15 percent. Hospitals love it because their reimbursement will be affected with rehospitalizations.”
Raising the Levels of Awareness and Expertise.
Reducing rehospitalizations from post-acute facilities isn’t only about the vigilance of the caregivers. It’s also about managing the complex transition to a care environment that provides fewer resources. “A lot of the problems that come up after discharge are the result of the narrower spectrum of services available,” says Dr. Hansen. So if the hospital doesn’t coach the patient on how to take her medications as she approaches discharge, the SNF can — if the provider has staff available to do so.
Some providers like Evercare, believing that post-acute patients may avoid trouble if they have easy access to more highly trained clinicians, are making that happen. “The staff in nursing facilities aren’t always adept at seeing and acting on signs of trouble; our NPs and PAs are,” says Dr. Shumacher. Life Care Centers of America is taking this approach to the next level, placing “SNFist” physicians in nursing homes full-time.
What’s the Return on Investment for Post-Acutes?
To what extent will post-acute providers see a return on an investment in reducing rehospitalizations? For many of these early efforts, though the improvement in outcomes is apparent, the financial ROI is not.
The Affordable Care Act, through incentives for ACOs and patient-centered medical homes, may eventually reward post-acute providers that keep their patients out of the hospital and penalize those that don’t, especially if SNFs or rehabs are vertically integrated with hospitals and primary care to treat a patient for a set, bundled payment. But that’s largely a promise for the future. “The ROI is complicated because there’s so much changing now with ACA,” says Dr. Hansen. “That creates a difficult environment for providers to structure care and do OK financially.”
John Rossheim is a writer and editor who covers information technology, careers and other topics in health care.
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