Studies have reported that around one-third of seniors residing in long-term care facilities are admitted to the hospital at least once a year. At least half of these admissions could have been avoided by better interventions or decision-making at the facility. Preventing unnecessary readmissions could save hundreds of thousands of elderly people from the many risks involved with transferring from a skilled facility to a hospital (transfer trauma, confusion and delirium, hospital-acquired infections, discontinuation of medications). It could also save Medicare millions or perhaps billions of dollars.
This, unfortunately, is not a new issue, but it has been in focus for the past few years. Reducing unnecessary admissions and readmissions to hospitals is no easy task. There are simply too many variables involved. Can’t nurses in the facility provide the level of care it takes to keep the resident in place? Does the doctor want to send the resident to the hospital “Just in case”? And, what about the family? Do they insist that their loved one must be discharged to the hospital because they feel better care will be provided there? Can’t skilled nursing centers deliver the same caliber of care?
The Big Picture
Why do skilled facilities have such a difficult time reducing hospitalizations and readmissions? A “big picture” answer is this: reducing hospital admissions isn’t one single problem. It involves a whole host of parts and pieces that must come together to minimize or eliminate unnecessary trips to the hospital. One of the main problems involves training and education. Nursing staff must be trained to effectively treat conditions that may trigger the need for hospitalization. Most facilities have care maps or clinical pathways for major health problems like cardiovascular failure, diabetes, and COPD. If these maps or pathways are followed appropriately, many admissions could be avoided. When they are not, most likely the resident is sent to the nearby hospital.
Another point of concern in skilled facilities is the ability to monitor and report status changes in residents that might require additional care, a phone call to the physician or as a last resort, a trip to the hospital. There is no one system or guideline that nursing home staff have to assess changes, communicate them to clinical staff, and then get that information to the physician, who would make the decision to keep the resident or send them out. For the most part, decisions are made before a thorough assessment is made, the nurse may be unsure, and the doctor wants to play it safe. But, there is a hefty price for the resident, Medicare and hospitals to pay.
In this day and age of liability and lawsuits, it is no wonder that some nurses and physicians would fear the outcome of their clinical decision. Some must feel damned if they do and damned if they don’t. It must be the perfect “Catch 22” situation. In some instances, the resident must be sent to the hospital, even though he or she was just admitted and discharged a month ago. Sometimes, readmission is just impossible to avoid for certain conditions. But, as the article stated in the beginning, many could be avoided.
And last, the family, especially adult children, may demand that mom or dad are sent to the hospital because they feel their loved one will receive superior care there. There is a misperception that hospital care, and in particular, nurses who work in hospitals, are better than those in skilled nursing facilities. This simply isn’t true.
Ruined Relationships
Hospitals are being fined by Medicare for excessive readmissions, and they are not happy about it, because these readmissions are coming mainly from skilled nursing and assisted living communities. Traditionally, these parties all should have good reciprocal relationships. The hospital admits elderly patients to senior living communities, who in turn discharges them to hospitals. This is a good give and take relationship, but excessive readmissions can impair it. Hospitals may not admit to nursing homes who “get them in trouble” with Medicare. Business can suffer on both ends.
Final Words on The Challenge of Reducing Hospital Readmissions
Hospital readmissions are a big and complicated problem. There seem to be too many variables impacting them. One step in correcting the problem is for hospitals to track discharges, admission and readmissions and share this information with the community of skilled and assisted living centers. Physicians from senior living can communicate and work with hospitals to reduce emergency admissions. Both can research software that would allow them to communicate more easily. There are solutions to each part of the readmission problem, but steps must be taken now to improve resident outcomes and Medicare spending before the situation gets worse.
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