James M. Berklan
James M. Berklan

For the long-term care operator who still thinks rehospitalizations are really just a worry for hospitals, it’s time to think again. Researchers are narrowing in on why nursing homes don’t always do what they’re asked to by referring hospitals.


A new study involving a Boston safety net hospital and 10 area nursing homes it referred patients to shows that nearly 25% of all recommendations for follow-up care were not followed.


The three most common discharge recommendations that weren’t acted on were subspecialty referrals, laboratory tests, and medication changes/monitoring. 


The researchers, who are affiliated with Boston University Geriatric Services, merely set out to document how often recommendations were not followed. They did not assign blame and said that in a majority of instances no reason for lack of follow-up could be discerned. They also pointed out repeatedly a lack of research in the area of hospital-nursing home discharges.


But several implications were clear, including, of course, that providers should expect much more research in this area. The key driver once again is trying to discover what moves rehospitalization rates. Long-term care providers have been warned numerous times, including in this space, that because hospitals now risk losing part of their pay checks, scrutiny will become more intense for everyone.


The Boston investigators found that the six-month rehospitalization rate in their small retrospective study was about 20%. That’s about the same as what other studies of rehospitalization rates have found. Though they could draw no direct association, the researchers wrote that there is “face validity to the premise that missed recommendations would lead to hospital readmissions, especially in patients with multiple comorbidities and functional impairments.”


Among the study’s findings: The likelihood of errors in communication and follow-up procedures rises “dramatically” as the patient moves among more sites. In addition, as the number of recommendations rose, so did the odds of non-compliance.

Besides the relatively small size of the study (51 patients’ records), the researchers noted several other limitations. They also acknowledged that nursing home operators could have had valid reasons for not following some recommendations, including having “expertise in NH care” that acute care providers did not. SNF operators also might have simply missed a recommendation and other recommendations might not have been implemented because the patient was discharged from the nursing home before they could be acted upon.

While providers wait for the next, more invasive shoe to fall, we can make a few conclusions from the implications of the study. Among them:


It is becoming more and more likely somebody will be looking closer at your transitioning practices in the near future. “To date, there are no studies which assess the completion of follow-up items through the entire episode of the transition of care in the [nursing home],” report authors noted. Count on this to change.


If you’re on the receiving end of a patient transfer, you really ought to be making more certain that you get all the recommendations from discharging hospital staff — and in a clear, complete format.


Electronic health records received another indirect endorsement and will continue to grow in use. The hospital in the study used electronic records while all the nursing homes still were using written records. (Hospital records were, however, accessible via the Internet.) To cut down on miscommunication, especially for patients bouncing to multiple sites, it’s only logical that having everyone able to consult the same unified, typewritten record is going to reduce errors and lack of follow-up. 

In fact, study authors noted that the rate of nonfollow-up was less in this study than in others. “We believe that the use of an EHR is a major reason,” they wrote.  

The universal transfer form recently put out by the American Medicaid Directors Association should be more widely adopted.

Personal care coordination services, or those communities that can assign someone to closely follow-up on recommended tests, doctor visits and lab work, will present significant value to operators and their customers.

Perhaps the first thing that should be done — on the ground and in the drawing rooms of electronic health records companies — is to formally add an “outstanding issues” section to every hospital patient’s discharge summary. The health system in the study has since done this with success.

Study authors strongly implied that post-acute providers were dropping the ball on transitional care. But the investigators also noted that documentation about pending test results and appropriate follow-up measures often were lacking.

James M. Berklan is McKnight’s Editor. Follow him @LTCEditorsDesk.