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SNFs often have high number of readmissions
INTERACT intervention can help
Research has shown that close to one in four Medicare patients transitioned from the hospital to skilled nursing facilities are readmitted to the hospital within 30 days. This is less than ideal, especially in these times when hospitals and other providers have to meet a growing list of federal quality standards.1
This revolving door of rehospitalization cost Medicare $4.34 billion in 2005 and increased the likelihood of medical errors related to care coordination, a study found.1
A new study also found a high percentage of readmissions from skilled nursing facilities (SNFs), suggesting the problem is common and related to both an elderly population and a lack of attention to transitional care initiatives.2
"Our study looked at one elderly population almost exclusively Caucasian in a non-teaching community hospital that does not have any vertical integration or own a skilled nursing facility," says Joseph G. Ouslander, MD, associate dean and professor in the medical school of Florida Atlantic University in Boca Raton, FL.
The new study found that one in five patients, ages 75 and older, who were discharged from the hospital to a SNF were readmitted to the hospital within 30 days, and one-third of the readmissions occurred within just one week of discharge.2
"We had two to three key findings," Ouslander says. "The most important involved the diagnoses associated with hospitalizations and rehospitalizations, and a large hunk of these were due to cardiovascular conditions, infections, and renal failure probably due to electrolyte imbalance and dehydration."
Investigators highlight the need for SNFs and providers working to make safe transitions in care to follow existing care protocols and care pathways for managing these conditions.
"One of the main things that this study points out is, you will get a big bang for the buck if you have hospitals working with nursing homes on care protocols for those conditions," Ouslander says.
Another finding was that most of the time the patient's readmission diagnosis was different from the initial admission hospital diagnosis, he notes.
For example, when data on patients with congestive heart failure were pulled, investigators found that 60% of the time their readmissions were for diagnoses other than heart failure, he adds.
"I think that points to the complexity of these patients," Ouslander says. "They have multiple conditions that can exacerbate each other."
Both Ouslander's and previous research point to transition problems and breakdowns in education and continuum of care. The easiest solution is for hospitals, SNFs, and other community providers to follow existing interventions and improve their communication and education efforts.
The Intervention to Reduce Acute Care Transfer (INTERACT) is an example of an intervention that could improve hospital-to-SNF transitions.
Ouslander's group developed INTERACT as a quality improvement program for nursing homes with tools and strategies for identifying conditions early and trying to manage them in the nursing home. The intervention also has some educational material and tools for hospitals, as well. These are available for a free download at the INTERACT website: http://interact2.net/tools.html.
One of the nursing home tools is an early warning tool that offers brief instructions to nursing home staff. It asks staff if they have identified an important change while caring for a resident and to circle the change and discuss it with the charge nurse before the end of their shift.
The INTERACT II Tools, educational materials, and implementation strategies were developed by Ouslander, Gerri Lamb, MD, Alice Bonner, MD, Ruth Tappen, MD, and Laurie Herndon, MD, with input from direct care providers and national experts in a project supported by the Commonwealth Fund based at Florida Atlantic University.
Initial versions of the INTERACT Tools were developed by Ouslander and Mary Perloe, MS, GNP, at the Georgia Medical Care Foundation with the support of a special study contract from the Centers of Medicare & Medicaid Services.
The instructions follow the acronym STOP AND WATCH:
Seems different than usual
Talks or communicates less than usual
Overall needs more help than usual
Ate less than usual
Not because of dislike of food
Drank less than usual
Agitated or nervous more than usual
Tired, weak, confused, or drowsy
Change in skin color or condition
Help with walking, transferring, toileting more than usual.
Another tool, called the Nursing Facilities Capability List, provides hospitals with a way to assess a nursing facility's ability to handle patients with different medical needs.
"This tool is so the hospital can know what the nursing home is capable of doing, and it's to promote good communication both verbally and in writing," Ouslander says.
"We also have some educational material on advance care planning because some rehospitalizations are people in the end stages of life, and they haven't elected to have comfort care or hospice care yet," Ouslander says.
Another strategy that would help improve hospital-to-SNF transitions is better use of health information technology so that critical data are readily available to people during the transition period.
"Having links between hospital electronic records and nursing homes is important so that people in nursing homes can see the critical information," Ouslander suggests. "Also, there should be more phone calls between doctors or from nurse practitioners to doctors to ensure that when someone is being discharged their care is being followed critically."
A third strategy is to have hospitalists follow patients into SNFs to provide continuity of care, he says.
"The major caveat is that hospitalists normally are not trained in geriatrics and long-term care," Ouslander notes.
"The American Directors Association, representing several thousand medical directors of nursing homes, is working on developing competencies for physicians and nurse practitioners who work in nursing homes," he adds. "Hospitalists working in collaboration with nurse practitioners could really improve the transition and continuity of care and reduce readmissions."
1. Mor V, Intrator O, Feng Z, et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010:29(1):57-64.
2. Ouslander JG, Diaz S, Hain D, et al. Frequency and diagnoses associated with 7- and 30-day readmission of skilled nursing facility patients to a nonteaching community hospital. J Am Med Dir Assoc 2011;12(3):195-203.
Joseph G. Ouslander, MD, Associate Dean, Professor, Medical School, Florida Atlantic University, Boca Raton, FL 33431. Email: email@example.com.