Rehospitalizations can be avoided, expert emphasizes

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Commonly overlooked clinical indicators can lead to a nursing home resident being transferred, an expert advised Monday.

“We don't want to have hospitalizations that are avoidable,” said Lisa Hohlbein, RN, RAC-MT, CDP, CADDCT, a curriculum development specialist at AANAC. Her comments came, during a Monday session at the American Health Care Association and National Center for Assisted Living convention in San Antonio.

These indicators include decreased intakes, mood and behavior dismissed as dementia, a slight change in ADLs, decreased activity level due to pain, and changes in blood pressure, especially systolic, she said.

Examining these indicators can catch signs that may lead to sepsis, she added.

“Unless they are extremely immunocompromised, they don't flip a switch and go septic,” Hohlbein said.

The INTERACT process is a useful way to reduce hospitalizations, Hohlbein said, including using the Situation, Background, Assessment, Recommendation (SBAR) component. This includes a script for a nurse when calling the physician or nurse practitioner to discuss a resident's change in condition.

“Not everyone is comfortable calling the doctor,” Hohlbein noted. “This is an area where you can watch nurses grow."

Another component is medication reconciliation, and establishing which nursing home residents are receiving new medications. A third of residents who go to the hospital with a medication list have a discrepancy, Hohlbein said. When engaging hospitals, a Nursing Home Transfer Form and Capabilities List can reduce communications problems. For example, “If you don't take trachs, the hospital needs to know not to send you trachs,” she explained.

Data also can be studied to see population trends -- and can guide daily stand-up and weekly staff meetings, according to Janet Snipes, NHA, administrator at Holly Heights Nursing Center in Colorado, and Christine K. Boldt, Vice President, Operations at Benedictine Health System in Minnesota.

Leadership rounding is critical, but should not involve “going around with a clipboard and look like a state surveyor", Boldt said.

That “is going to look like a ‘gotcha process,'” she said. Instead, daily rounds can involve recognizing positive actions when an administrator sees it, and building the team.

“Engage staff through contests,” Snipes recommended, noting her facility passed out poker chips to supervisors who could hand them out when they saw good work. Employees could redeem the chips for prizes. Rewarding employees with a latte machine for a day and handing out lottery tickets, are other ideas.

Since certified nursing assistants' actions often influence reimbursement, they should be empowered and educated on why their roles matter, Snipes and Boldt said. Point-of-care documentation involves having CNAs chart as they go, rather than at the end of their shift. Point-of-care kiosks in the hallway and dining rooms are one way to make this possible.