The Real Nurse Jackie

Unicorns, leprechauns, CBO Scoring and other mythical things

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I recently attended the National Transition of Care Coalition Summit in Washington. It was an eye-opener.

Many of the notable discussions targeted the high prevalence of hospital readmissions and medical errors pointing at the inadequacies of care transitions and their adverse economic implications to the U.S. health care system and the negative consequences to the patients impacted by this.

So, of course, as always, questions arise as to the negative consequences of the perverse payment system of the dreaded three-day hospital stay requirement to “skill” a resident of a nursing facility. I mean, really, if you are in a Medicare HMO or a Nurse Practitioner Care Model, you don't have to send the resident out to an acute care facility to skill them.

Based on very strict criteria, the resident can be skilled based on need. But not if you are in a traditional Medicare plan. Hmmmm, a $10,000 per day hospital stay versus a $500 per day SNF stay? (OK, my numbers might not be perfect but I think they are close.)

I wonder which costs less? This is not going to change in at least the next five years as the Congressional Budget Office has scored that sending a resident out to the hospital will save Medicare a bazillion dollars versus following a very strict criteria to skill a resident and allow them to remain in place.

Let me try to break this down a bit. The CBO is responsible for economic forecasting and fiscal policy analysis, scorekeeping, cost projections, etc. The CBO enables Congress to have an overview of the federal budget and to make overall decisions regarding spending. In addition, the CBO provides Congress with basic budget data.

The CBO is required to develop five-year cost estimates for carrying out any public bill or resolution reported by congressional committees. At the start of each fiscal year, the CBO also provides five-year projections on the costs of continuing current federal spending and taxation policies. So basically, the CBO continues to tell Congress that the three-day stay will save Medicare a lot of money. (And there is a little man with a green outfit waiting with a pot of gold under a rainbow for me!)

OK, why did I say that? Because CBO scoring does not have to be based on research from the actual setting. Scores are based on evidence from similar policies enacted in the past and on the results of various economic models.

So no research or a demonstration project on the cost of hospitalization versus skilling based on strict criteria has been done. (Does anyone remember back in 2009 the Pharmaceutical waste and short fill issue? All of that was started on CBO scoring based on community based setting with retail pharmacy numbers.) Experientially, we in this practice area know that allowing us to keep our residents in our own environment will save money and lives.

Besides the economic costs, let's look at the harm: Medication errors harm an estimated 1.5 million people each year in the United States, costing the nation at least $3.5 billion annually.1 One study found that, on discharge from the hospital, 30% of patients have at least one medication discrepancy.2 On average, 19.6% of Medicare fee-for-service beneficiaries who have been discharged from the hospital were readmitted within 30 days and 34% were readmitted within 90 days.3 Transfer to the ER or hospital is costly, is disruptive for patients and can expose patients to many risks 4, including delirium, under nutrition, serious infections, skin breakdown, and adverse drug reactions.5

But, hey, stick with the CBO scoring by all means and ignore the real evidence. After all, on Dec. 3, 2012 the state news agency in North Korea reported they found an ancient unicorn lair in the capital. (Experts on the country say this is likely leadership using propaganda to make themselves seem super human.) But who am I to judge?

As this is my last blog of the year —yes, we are all still here despite the Mayans' prediction that the world would end last week (and this prediction coming from a tribe of people, mind you, that felt they had to sacrifice thousands of people every night to ensure the sun would rise the next day) — let my wishes for the next year be ones of peace, harmony and some common sense in the government. (OK, where did they say that Unicorn lair was?!)

Just keeping it real!

Nurse Jackie

1.     Harris, G, “Report Finds a Heavy Toll from Medication Errors,” New York Times, 21 July 2006.

2.     Kwan, Y, Fernandes, OA, , JJ et al., “Pharmacist medication assessments in a surgical preadmission clinic,” Arch Intern Med, 2007;167:1034-40.

3.     Forester, AJ, Murff, HJ, Peterson, JF, et al., “The incidence and severity of adverse events affecting patients after discharge from the hospital,” Annals of Internal Medicine, 2003:138(3):161-7.

4.     Creditor, M. “Hazards of hospitalization of the elderly.” Ann Int Med 1993;118:219–223.

5.     Hutt, E et al. “Precipitants of emergency room visits and acute hospitalization in short-stay Medicare nursing home patients.” J Am Geriatr Soc 2002;50:223–229.

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, a 2012 APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse who is also the director of clinical affairs for the American Medical Directors Association. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. She has not starred in her own national television series — yet. 


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The Real Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, a 2012 APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse who also is the director of clinical affairs for AMDA - The Society for Post-Acute and Long-Term Care Medicine. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.

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