Partnering to reduce readmissions
Zachary Palace, M.D.
In recent months, much has been written in the media about reducing the 30-day re-hospitalization rates of Medicare beneficiaries. In truth, the primary driver behind this movement is largely financial. As a result of new CMS rules implemented in October 2012, hospitals are now facing stiff penalties for discharged patients with select diagnoses being readmitted within a 30-day window period. With the implementation of the Affordable Care Act, greater emphasis is now being placed on developing initiatives, such as accountable care organizations (ACOs) to reduce costs to the healthcare budget by improving post-discharge care and reducing avoidable re-hospitalizations, thus realizing a shared savings to the system.
As a long-term care geriatrician, it is my core belief that clinicians need to recognize the true value of what we can accomplish together by improving the quality of patient care through reducing avoidable hospitalizations. The public has a firmly held myth that the best place to get great care is in the hospital. I would argue that this is often not the case, particularly in the nursing home population. With round-the-clock nursing care and ongoing supervision and observation, the nursing home environment is actually very well-suited to care for many of the medical issues for which patients are unnecessarily sent out to hospital.
Reducing the rates of hospitalization of nursing home residents is all about practicing good geriatric medicine and “doing no harm” to the patient. As with any important decision, the clinician must recognize the need to perform a cost-benefit analysis, such as, “Is there a way we can safely treat this patient at the nursing facility?” We need to recognize that the elderly are much more susceptible to the development of serious complications associated with an inpatient hospitalization. These complications include the development of hospital-acquired infections. The natural immune response weakens with advancing age. In the hospital environment, the elderly are exposed to an overwhelmingly hostile microbial environment of antibiotic-resistant organisms, which is often associated with development of new infections and increasing lengths of hospital stay. I often refer to this observation as “the longer you stay, the longer you stay” phenomenon.
Decreased mobility due to prolonged bed rest is another major complication associated with an inpatient hospitalization. Medicare recognizes this with the three-day qualifying stay rule, although muscle disuse atrophy begins to occur almost immediately, and necessitates skilled post-acute rehab services upon discharge. Another adverse outcome resulting from prolonged bedrest is the development of hospital-acquired decubitii. The human toll associated with healing these painful wounds is significant to patients and the caregivers. In reality, elderly patients never leave the hospital physically stronger than when they were admitted.
The hospitalization of patients with a diagnosis of dementia is, perhaps, most devastating to patients and their families. These patients often develop a stable comfort zone in the familiar home-like environment of the nursing facility. Acute adjustment reactions commonly occur when a patient with cognitive impairment is subjected to an unfamiliar hospital environment. In the fast-paced hospital setting, “acute care” staff are often less clued-in to the “chronic care” needs of the frail cognitively impaired patient. Furthermore, the loss of day and night cues, as well as the increased prevalence of superimposed delirium can adversely affect these residents. The end result of agitated behaviors and increased levels of confusion in these patients often results in pharmacological interventions, including the introduction of psychotropic medications to control these symptoms.
Throughout my career at The Hebrew Home, I have recognized the benefits of treating nursing home residents “in place” and avoiding hospitalization in cases when it is clinically feasible. It is about practicing the principles of geriatric medicine and is truly a win-win situation. In so doing, our facility has been able to maintain its 30-day re-hospitalization rates well below national averages. Our patients benefit when their medical needs can be met within the facility, avoiding all the above-mentioned complications. Families appreciate the role the facility can assume in caring for the acute as well as the chronic medical concerns of their relatives and loved ones.
Lastly, by focusing on providing better quality care in the nursing home, this results in a very significant cost-savings to the healthcare system.
Zachary J. Palace, M.D., CMD, FACP, is a geriatrician and medical director of The Hebrew Home at Riverdale, Bronx, NY.