Vol. 18 • Issue 2
• Page 39
What do the following scenarios have in common?
A hospitalized 78-year-old woman is 3 days post total knee arthroplasty, and her husband requires extensive assistance with activities of daily living.
A 92-year-old man who lives in an assisted living facility was admitted to the hospital 10 days ago for treatment of pneumonia. He has responded well to antibiotic therapy but is weak and unable to care for himself.
A 66-year-old single woman with a traumatic leg fracture lives in a "vintage" house with no bedrooms or bathrooms on the first floor. No family or friends are available to help.
The commonality is this: All these patients require skilled subacute care.
Almost universally, the first choice for older adults being discharged from the hospital is to go directly home. This plan is often thwarted, however, and a detour to a skilled nursing facility (SNF) for subacute care with additional recovery and rehabilitation time is necessary. Although the specific need for subacute care may vary, patients admitted to SNFs are at some risk and require comprehensive care. Common challenges for this population include polypharmacy, untreated or undermanaged pain, situational anger or depression, complex chronic disease comorbidities, and family discord.1Once transferred to subacute care, it can be difficult to avoid a return to the hospital. Typically, patients transferred to nursing homes are most vulnerable in the first few days after admission, often for reasons related to care fragmentation.2,3Common problems that may have been missed during hospitalization include cognitive impairment, delirium, depression and functional impairment.4Lack of information and support to residents and families about expectations and limitations of subacute care and lack of patient familiarity by covering on-call doctors are additional causes of overhospitalization.5In a large study of SNF residents, researchers found that hospital stays were 1 day longer and more expensive for SNF residents compared with community-dwelling older adults.6An estimated 28% to 45% of hospitalizations might be avoided with high-quality subacute care.7Nurse practitioners are well qualified to meet the complicated health needs of older adults who need subacute care. The increased use of NPs in nursing homes provides cost savings and contributes to improved outcomes, including decreased hospitalization rates.6,8,9
This article outlines the Skilled Nursing Home Network (SNHN) program at Alegent Health in Omaha, Neb. The SNHN was designed to provide coordinated, high-quality attention to SNF patients and to decrease unnecessary rehospitalizations for patients requiring subacute stays after hospitalization. Data and discoveries from the first 3 years of the program's operation are shared here.
The Network Team
The SNHN team includes four NPs, seven physicians and a social worker. NPs provide routine and emergent care to residents who choose the SNHN program. Initial visits generally occur within 24 hours of admission and include medication reconciliation, a comprehensive history and physical, and review and refinement of the plan of care. Weekly follow-up visits focus on identifying and resolving issues that interfere with rehabilitation and updating the plan of care. Results are documented in a SOAP note. NPs cover call 24 hours a day, 7 days a week and typically return calls within 10 minutes, which increases satisfaction and quality of care. Table 1 outlines monthly workloads for the NPs.
Due to the challenging and complex nature of subacute care, collaboration and backup by physicians are imperative. Physician services are primarily consultative in nature, but they also meet Medicare required visits and certifications. Of note, the inclusion of physicians in the model was important to building acceptance of the program by area doctors. SNHN physicians and NPs meet quarterly to review clinical and facility-related issues.
A master's-prepared social worker is available to augment but not duplicate processes and services provided by the nursing home social worker. A data analyst rounds out the team and assists with data collection, scheduling and billing.
Settings
SNF partners are chosen based on interest in the program and census of Medicare patients who require skilled services. At the time this article was published (February 2010), six facilities were participating in our SNHN. The goal is to have a minimum of five patients on service in each facility at all times.
We have found that the model works best if an NP is in each facility at least 4 hours per week. A one-page covenant, signed by each facility and the care providers, outlines expectations for the facility and the SNHN team (e.g., call coverage, education, and terms of participation and cancellation).
Admission and Follow-Up Process
When patients require subacute care, they are often surprised that their physicians do not visit SNF facilities; most needs are triaged via fax or phone calls. Changes in plans of care or treatments are often delayed while subacute staff members wait for answers. If transportation to the primary physician's office is required, costs are significant.
Patients are referred to our SNHN by primary care physicians, hospital discharge planners, SNF admission coordinators, patients and families. A doctor's order is not required. The SNHN provides services only while the patient receives subacute services covered by Medicare. Upon admission, primary care providers are notified that the SNHN will follow the patient. When the patient is dismissed, the primary care provider receives copies of discharge summaries. Residents who require rehospitalization return to their primary care providers. Charges are submitted for Medicare, Medicaid or other insurance remimbursement. No direct charge is made to the facility.
Patient Profile
Table 2 outlines resident profiles including demographics, length of stay (LOS), rehospitalization rates and total number of scheduled medications at admission and discharge.
The SNHN has enjoyed double-digit growth each year, with limited marketing. In 2005, the average hospital LOS for patients 65 and older was 5.5 days.10Over the first 3 years of the SNHN, the average hospital LOS for patients averaged 10 to 10.8 days, nearly twice the national average and consistent with higher acuity of patient presentations. The average skilled facility LOS for SNHN patients after reaching the facilities was slightly shorter (26 to 29 days) than the national average of 28.8 days for Medicare SNF utilization for nonhospital facilities.11
Primary and secondary diagnoses have remained consistent over the 3 years, topped by orthopedic-related surgeries and injuries, acute illnesses such as pneumonia and sepsis, and chronic illnesses such as heart failure, diabetes, osteoporosis, arthritis, cancer and strokes. Due to fraility and comorbidities, about 5% of admissions require end-of-life planning or hospice care and about 20% need long-term care placements. NP participation in family conferences and care planning meetings are highly valued in these situations.
Hospital Readmissions
Annual readmissions to hospitals in the SNHN ranged from 8.8% to 10.9% during the first 3 years. These outcomes are much lower than national averages (25%).7These low rates may be attributed to the identification and resolution of problems during both admission and weekly visits. Also, our nurse practitioners take call on these patients so transfers are reduced.
Transfers of patients to the emergency department or for hospital readmission are difficult and costly for patients, staff members and families.12It is important that patients are only transferred for conditions that warrant hospitalization. It is also important that reasonable skilled nursing interventions have been implemented.12Common causes of hospitalization after SNF care include infections, heart failure, ischemic heart disease, hip fracture, digestive disorders and volume depletion.13For the SNHN, primary reasons include change in level of consciousness, signs of sepsis, chronic obstructive pulmonary disease and cardiac symptoms.
Medications
The average nursing home resident receives 8.8 unique medications.14In all 3 years of operation, the average number of medications for SNHN patients exceeded the national average. Medication management is an ongoing process, with reconciliation at both admission and dismissal. Special attention is paid to iron levels and medications for pain, constipation and anticoagulation. The Beers criteria, which list inappropriate medications for older adults, provide valuable guidelines for making decisions and providing justification for regimen changes.15The mean number of scheduled medications for SNHN patients decreased from admission to discharge.
The decline was greater in the first year (1.8) than the second (0.4) or third (0.05). The change may be attributed to the adoption of greater adherence to the guidelines for calcium (1,200 mg daily) and vitamin D (800 mg daily) replacement for patients 50 and older.16This was initiated in the second half of the second year of the program.
Pain Control
The use of scheduled pain medications along with alternative and adjuvant pain modalities is a strength of the SNHN. On admission and discharge, patients are asked to rate their pain in the prior 24 hours on a 4-point Likert scale. Average pain levels decreased from an admission mean of 1.35 (mild to moderate) to a discharge mean of 0.75 (none to mild). At discharge, patients are also asked to rate their overall pain control during the stay on a 5-point Likert scale. The mean score was 2.13 (good to very good).
One factor that has been overcome by the SNHN is the problem of residents being admitted with orders for opiod pain medications but no prescriptions. Ongoing education of SNF staff about the importance of effective pain management, including prompt attention to request for medication or therapies, has been provided by the SNHN NPs. The need to proactively attend to a bowel regimen for residents on opiod therapy has been well received by patients and staff.
Putting It Into Practice
Based on 3 years of data, processes and outcomes, we believe that an NP-led SNHN provides excellent care to a vulnerable population of older adults. Physicians have grown to trust that patients will return to their practices after the subacute stay. Skilled nursing home administrators frequently comment on the thorough and prompt attention to requests. Staff members have more time to attend to residents' needs because they are not waiting for answers to their questions.
Decreased costs associated with medications and transportation are other benefits. Hospital discharge planners and SNF admission staffers are able to reassure patients and families that they will receive attention for their complex needs with this option.
The SNHN has been able to dramatically decrease rates of return to hospitals. As the reimbursement structure for readmission of Medicare patients becomes more restrictive, proven programs such as this one, which decreases rehospitalization and provides high-quality care, will be especially desirable.
Communication among the SNHN staff and patients and families is especially important. Not all SNF patients go home. Frequent communications about progress and challenges help with decision making.
With this model as in all areas of healthcare, it is important to ensure that each return to the primary care provider is smooth and efficient - with clear, comprehensive and succinct documentation. The creation of an accurate, understandable medication list with prescriptions to fill the gap until the return primary care visit is crucial.
Brenda Bergman-Evans is a gerontologic nurse practitioner who is coordinator of the Nursing Home Network at Alegent Health Center in Omaha, Neb. She has a PhD in gerontologic nursing and is the chairwoman of the Nebraska APRN Board.
References
1. Buxbaum RC. The evolution of subacute care. Long-Term Care Interface. 2006;7(7):29-32.
2. Lee VK, et al. If at first you don't succeed: efforts to improve collaboration between nursing homes and a health system. Advanced Practice Nursing e-Journal. 2004;4(3). Available at: http://www.medscape.com/viewarticle/487323. Retrieved Nov. 4, 2009.
3. Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geri Soc. 2003;51(4):549-555.
4. Lyons WL, Landefeld CS. Improving care for hospitalized elders. Ann Long-Term Care. 2001;9(4):35-40.
5. Buchanan JL, et al. Nursing home capabilities and decisions to hospitalize: a survey of medical directors and directors of nursing. J Am Geriatr Soc. 2006;54(3):458-465.
6. Barker WH, et al. Rates, patterns, causes and costs of hospitalization of nursing home residents: a population based study. Am J Public Health. 1994;84(10):1615-1620.
7. Medicare Payment Advisory Commission. A Data Book: Healthcare Spending and the Medicare Program. Washington, D.C.: Medicare Payment Advisory Commission; 2006.
8. Mezey M, et al. Experts recommend strategies for strengthening the use of advanced practice nurses in nursing homes. J Am Geriatr Soc. 2005;53(10):1790-1797.
9. Intrator O, et al. Facility characteristics associated with hospitalization of nursing home residents: results of a national study. Med Care. 1999;37(3):228-237.
10. DeFrances CJ, Hall MJ. 2005 National Hospital Discharge Survey. Advance Data from Vital and Health Statistics, 385. Hyattsville, Md.: National Center for Health Statistics; 2007.
11. Medicare and Medicaid Statistical Supplement. Centers for Medicare & Medicaid Services: Data from the Medicare Data Extract System. Available at: http://www.cms.hhs.gov/MedicareMedicaidStatSupp/downloads/07Fig6.2.pdf. Accessed Nov. 4, 2009.
12. Saliba D, et al. Appropriateness of the decision to transfer nursing facility residents to the hospital. J Am Geriatr Soc. 2000;48(2):154-163.
13. Malone M, Danto-Nocton E. Improving the hospital care of nursing facility residents. Ann Long-Term Care. 2004;12(5):42-49.
14. Simoni-Wastila L, et al. Over-the-counter drug use by Medicare beneficiaries in nursing homes: implications for practice and policy. J Am Geriatr Soc. 2006;54(10):1543-1549.
15. Fick DM, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163(22):2716-2724.
16. National Osteoporosis Foundation's Updated Recommendations for Calcium and Vitamin D Intake. Available at www.nof.org/prevention/calcium_and_VitaminD.htm. Accessed Nov. 4, 2009.
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