Long-Term Care Survey Alert

Published on Mon Jan 28, 2008 PDF

It's time to get on this bandwagon.

Preventing avoidable rehospitalizations protects residents from hospital-related negative outcomes -- and puts your nursing facility ahead of the curve for what will likely become a growing focus for payment and surveyors.

The June 2007 Medicare Payment Advisory Commission report to Congress cited alarm over SNF rehospitalization rates. And the Centers for Medicare & Medicaid Services' SNF pay-for-performance demonstration, currently being cleared by the Office of Management and Budget, includes avoidable rehospitalization as a quality measure, a CMS spokesperson tells Eli.

Follow these four key strategies to ensure residents don't head back to the hospital unnecessarily.

1. Develop a systematic way to detect subtle, early signs of acute illness. Acute-care nurse Janet Cuddigan, RN, PhD, has seen elderly nursing home patients come into the emergency department and ICU with dropping blood pressure and sepsis. "And when you read the chart from the nursing home, you see some subtle changes" that often indicate bigger problems, she says. For example, the notes relay how the person wasn't quite as oriented as usual or wasn't as enthused about his usual activities.

The clinical bottom line: "Nurses should trust those subtle clues and look for a source of infection, such as a pressure ulcer or UTI," advises Cuddigan, a nursing professor at the University of Nebraska. "You don't have to pull out the big guns in every case and culture everything," but you shouldn't ignore those early signs and symptoms, she cautions. Try to identify the source.

Develop a reporting format for CNAs that will alert the licensed nurse to subtle changes in a resident's status before the nurse's shift ends, suggests Clare Hendrick, a geriatric nurse practitioner and consultant in San Clemente, CA. For example, ask CNAs to give report during the day shift right after lunch to let the licensed nurse know how the morning went -- and again at the shift's end, advises Hendrick. "That way, the licensed nurse can compare the morning to the afternoon to detect subtle changes."

The evidence speaks: One published study found that nurse aides were good at identifying certain changes, including weakness, needing more help with ADLs, agitation or diminished verbal responsiveness from the resident's baseline, noted Bruce Robinson, MD, in a presentation on acute change in condition at the March 2007 American Medical Directors Association annual meeting.

2. Implement a standardized process that evaluates quickly whether to hospitalize a resident showing an acute change in condition. "Identify an RN to be on call who has critical thinking and documentation skills to be involved in that process," advises Joy Morrow, PhD, RN, senior clinical consultant with Hansen, Hunter and Co. in Beaverton, OR.

"Then document the thinking and rationale as to why the team decided to hospitalize the person or not. As part of that assessment, you have to evaluate the interactions of the person's condition and comorbidities."

Also, develop a format for the licensed nurse to contact a physician about a resident's acute change, Robinson suggested (see his sample reporting format, p. 12).

In making the decision to hospitalize, the physician and team have to identify the "benefits and burdens" of moving the resident, Robinson adds.

The resident's or family's expectations and goals for care figure in to the decision-making (see a script on p. 10 that nurses can use to get family input about a resident's change in condition).

Keep in mind: "Some residents would choose a quick death and com-fort care, and others want to do everything they can to prolong the final phase of their life," Robinson tells Eli.

3. Implement strategies to prevent and assess for problems that typically occur during a resident's transition from the hospital to the SNF. The medical director can work with the hospital physicians to come up with ways to help ensure patients have a smooth transition from the hospital to the SNF, which can help prevent the need for rehospitalization, says David Mehr, MD, an associate professor of medicine at the University of Missouri-Columbia.

For example, "ideally, hospital-based physicians would move a patient to the long-term care facility medication regimen as much as possible at least a day before discharge" to the nursing facility, Mehr says. "This is a good issue for medical directors to work with hospital physicians on."

Real-world practice: Mehr's geriatric practice insists that its geriatricians caring for people in the nursing home consult with the patient's hospital physician the day before discharge to look for delirium or other issues that could cause problems in the nursing home.

Don't let this mindset get the best of residents: Diane Brown, NHA, thinks there's a tendency for nursing facilities to accommodate residents' expectations that they won't be bothered as much by nursing staff as they were in the hospital.

"But without monitoring the person closely during the transition, you can miss the early signs and symptoms of relapse," cautions Brown, CEO of Brown LTC Consulting in Peabody, MA.

4. Implement a QA program to analyze rehospitalizations. Long-term care expert Nathan Lake, RN, BSN, MHSA, finds many facilities don't systematically track rehospitalizations -- particularly repeats.

Staff may have a "collective memory that Mrs. Jones has been in the hospital three times this year, but they don't track rehospitalization as a quality measure," says Lake, Seattle-based director of clinical design for American HealthTech.

In developing a QA process: See if the facility is rehospitalizing residents with conditions that a SNF should be expected to handle or that can even be treated on an outpatient basis, such as a physician office, advises Morrow. Those conditions include pneumonia, ones that require IV antibiotics and fluids and/or a condition that requires a more potent diuretic than an oral one, she adds.