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Preventing Hospitalization

Reducing unnecessary hospital readmissions at end of life begins with good communication.

Hospital readmissions have been a focus for healthcare providers for several years, particularly with the emphasis on the financial consequences of hospital readmissions within 30 days of discharge from the hospital. This article will identify an important aspect of controlling unnecessary hospital readmissions from the perspective of residents at end of life, and specifically for those residents who are on palliative care or hospice programs.

MDS defines a hospice program as services provided for the palliation and management of terminal illness and related conditions. The hospice unit or program must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider.

Defining palliative care calls for a broader view. Palliative care is about living, as well as the ability to provide access to needed care with the goal of obtaining the best possible quality of life. Residents who have chosen palliative care have made the decision, along with their physician and family members, to change from curative goals to comfort goals.

Palliative care becomes appropriate when the focus on curing a resident who has a chronic health condition becomes an impediment to quality of life and the resident decides not to spend his or her remaining time on aggressive, curative procedures. At this point, medical intervention is focused on symptom management, including aggressive pain control. These types of interventions often can be provided effectively at a skilled nursing facility. Unfortunately, more often than not residents are sent to the hospital for treatment intervention due to issues such as lack of advance care planning and communication between the primary physician and physician specialists and the family members.

Hospital admissions as life draws to a close are intrusive and can diminish life quality. Any transfer to the hospital should occur in the context of the resident's expressed wishes; however, because there are risks as well as benefits of care in a hospital, it is important to make the right decision. The decision is based on a number of factors. How the nursing home resident and their family members view the benefits and risks of care in the hospital as opposed to the nursing home is a major factor. Research has shown that some hospitalizations may be unnecessary. Whether hospitalization can be prevented depends on the resident's condition, the ability of the staff to provide the care necessary in the nursing home, and the preferences of the resident and his or her family.

Physicians must communicate with residents and their families about advance directives, however all staff should be able to communicate the goals of care, preferences, and end-of-life care. These conversations should begin upon admission to the nursing facility and must be clearly documented during care plan meetings with the resident, family and interdisciplinary team. The conversations should include expectations for the course of the disease process including revisiting the advance directives at every stage as goals of care may radically alter as health status changes. The conversations should specifically address how the nursing facility can manage the care needs that will likely occur. Residents and family members are less likely to make a decision, such as whether to go to the hospital or not, in haste if they know what to expect as the disease process progresses and if they have confidence that the palliative and comfort care measures they previously chose can be provided safely and effectively in the nursing home setting.

Family members often push the physician and facility staff to admit their loved one to the hospital because they view the hospitalization as necessary to prevent suffering and pain even when a resident has an advance care plan in place stating they do not wish to be hospitalized. In these situations it is important to have ongoing conversations with the resident and their family members about their advance care planning decisions and the risks of hospitalization. INTERACT tools and resources are a valuable aid to providers who are looking for assistance with decreasing their hospital readmission rates at end of life. This information can be found at can be found at under the advance care planning tools section of the INTERACT Version 3.0 Tools For Nursing Homes.

Complications in Hospital Care
Nursing home residents are prone to many complications of care in a hospital for several reasons: older age, chronic medical problems, and the condition that caused the transfer all combine with the hospital environment to put nursing home residents at high risk for complications. These complications include: new or worsening confusion; more time spent in bed, which can increase the risk of blood clots, pressure ulcers, muscle weakness, loss of function which can lead to other complications; less sleep and rest due to tests, monitoring and noise; and Increased risk for falls with injuries, new infections and depression.

There are benefits of staying in the nursing home when a new symptom or condition occurs - assuming it is safe to treat the condition in the nursing home and staying in the nursing home is consistent with the preferences of the resident and his or her family. Treatment in the nursing home allows residents to: continue to receive care from staff members who know them, and who are able to respond to their individual preferences and needs; remain in a familiar environment with their personal possessions, and keep their individual routines as much as possible; avoid what is often an uncomfortable trip to the hospital and long delays waiting in the emergency room; avoid potential problems due to miscommunication between the hospital and the nursing home; and avoid other hospital-related complications identified above.

Communication between medical professionals is another area that is paramount to managing unnecessary hospital admissions at end of life. All medical professionals, the primary care physician, the specialist and the physician extenders, involved in caring for the resident must clearly understand what the resident's wishes are for end of life care and the orders for care need to consistently reflect those wishes. This can be a huge obstacle to consistent care orders and a difficult issue to address. The primary care physician should be charged with the communication to all those who provide orders for care of the resident in the nursing home setting. Facility staff needs to feel empowered to communicate to the primary care physician when there are orders that conflict with the resident's advance care planning wishes.

Finally, incorporating hospital admissions at end of life into the facility quality improvement program is crucial to preventing unnecessary admissions. Admissions at end of life and for residents in a palliative care program should be analyzed to determine if the admission is avoidable or unavoidable just the same as admissions within a 30 day timeframe from hospital discharge. The facility should look for trends that can be identified when unnecessary admissions occur and develop a plan of action to address the issues accordingly.

Reducing unnecessary hospital readmissions at end of life begins by engaging patients with serious, life-limiting illnesses in a discussion concerning their preferences for end-of-life medical interventions and intensity of care. The results are an improvement in the quality of end-of-life care. It is the right thing to do.

Sheila Capitosti is vice president of clinical and compliance services at Functional Pathways, Knoxville, Tenn. For more information: Contact:


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