John O'Connor

It’s not hard to see why federal regulators want fewer residents going to hospitals.

Such ambulance rides can be harrowing, avoidable and expensive. In fact, nearly half (45%) of hospitalizations among Medicare-Medicaid enrollees in SNFs could be prevented, regulators insist. If such a reduction were to occur, the nation’s annual healthcare tab would be trimmed by about $3 billion, according to federal estimates.

An experiment designed to target avoidable hospitalizations is getting started in central Indiana. There, 19 long-term care facilities are participating in a pilot program that aims to improve communication between acute and long-term care settings, while also making front line caregivers a bit more savvy. Dubbed the Optimistic Study, the initiative was developed by research-clinicians from Indiana University and the Regenstrief Institute.

As part of the program, specially trained nurses are stationed at the participating facilities. One aspect of their job is to provide education and training to the staff — as well as direct support to long-stay residents. They also lead care management reviews of such patients. This additional assistance helps improve chronic disease management, reduce unnecessary medications and clarify care goals, backers say.

In addition, nursing aides are being trained to recognize early warning signs of a resident’s changing condition. For example, aides are being taught that newly swollen feet might indicate heart failure. Aides and other staffers are also being trained to communicate rapidly with the resident’s medical team. That way, appropriate treatment can begin before a problem escalates to the point where hospitalization is required.

Some might scoff at the program’s initial $13 million price tag. But considering its potential payoff, the investment might soon be seen as money well spent.

John O’Connor is Editorial Director at McKnight’s.