Reducing hospital readmissions from nursing centers starts with analyzing the continuum of care—from the hospital setting to the nursing facility transfer, through any events and decisions that may lead to readmission.
Health care associations, policy institutes, and think tanks have already taken the initiative and are creating tools to help hospitals and nursing homes reduce rehospitalizations. A program called Interventions to Reduce Acute Care Transfers (INTERACT) II, created at the Georgia Medical Care Foundation under a special study contract with the Centers for Medicare & Medicaid Services, offers a comprehensive array of communication tools and checklists for nursing home staff members.
The INTERACT II tools include questionnaires and guidelines to help staff members make informed decisions at every step of the care continuum and help staff:
■ Better identify acute changes of condition and elevated risk levels;
■ Identify residents with the highest risk for developing acute change of condition;
■ Identify the causes of an acute change of condition and the feasibility of managing the resident within the nursing home setting; and
■ Effectively manage acute changes in condition.
The goal is to address one of the fundamental reasons why patients are needlessly transferred to hospitals—the assumption that certain status changes automatically require that a patient be rehospitalized.
In reality, there are many medical scenarios that skilled nursing centers can address competently and successfully. If a facility is prepared with the right equipment, if staff have the right training, and if the right procedures are followed, then many nursing home-to-hospital transfers could be avoided.
A rehospitalization reduction program at the University of Minnesota focused on identifying risk factors and designing a protocol around an interdisciplinary team approach for high-risk patients. In this approach, there are many medical scenarios that nursing centers like Revera Health Systems, Meriden, Conn., can address competently and successfully.
Testing this approach at a Minnesota nursing home, researchers were able to lower rehospitalization rates by 20 percent—33 percent lower than the national average.
Revera has taken the publicly available INTERACT II tools and adapted them to meet the needs of Revera facilities. The goals of Revera’s program are to improve bedside nursing assessment, improve communication to the physician about changes of condition, reduce off-hour calls to the physician for nonemergent issues, improve communication with interfacility transfers, and conduct quality reviews after each hospital/emergency room transfer to determine appropriateness of a transfer.

The Tools

Revera’s INTERACT program includes procedures and checklists that allow facility staff to identify patients at risk and make timely interventions to prevent the kinds of problems that can lead to a hospital admission.

Among the key tools employed by Revera’s program are Care Paths and Change in Condition File Cards.

The purpose of this color-coded (red for immediate action required and blue for reporting the next business day) system is to help guide the assessment and management of common changes in resident status that could result in acute-care transfers.

There are six Care Paths in the Revera INTERACT toolkit for conditions that commonly result in acute-care transfers: dehydration, urinary tract infection, lower respiratory infection, mental status change, fever, and chronic heart failure.

The file cards enable a nurse to conduct a quick snapshot of potential scenarios, thus saving time on assessment and the next steps for each patient.

Color-coded envelopes that include checklists are completed for every patient who is transferred to the emergency room for evaluation and treatment. The purpose of this system is to provide a single envelope with all the necessary forms needed to provide continuity of care.

Revera’s Quality Improvement Tool is used to review acute-care (nonelective) transfers of residents to the emergency room or direct admission into the hospital. It is used to identify patterns among acute-care transfers and possible ways to reduce avoidable transfers.

The Early Warning Tool is aimed at identifying changes in the resident’s condition, communicating changes to nursing staff, and identifying possible opportunities to prevent sending residents to the hospital.

Role Of Health Care Reform

The impending implementation of health care reform’s numerous provisions has prompted Revera to take a proactive approach to change.

With that in mind, Revera’s nursing centers have launched several initiatives designed to reduce readmissions, such as additional quality improvement programs, more specialists on staff, more nurse practitioners on staff to perform higher-level assessments, and expanded on-site specialty services such as including pulmonology and dialysis units in selected markets.

In-house specialty services and specialists on staff—at least in certain strategic areas—is one key to reducing rehospitalizations.

Some physicians and hospitals have approached Revera to inquire about its centers’ ability to provide more specialized care services, particularly pulmonary care. Since many patients today have chronic obstructive pulmonary disease, or COPD, as a secondary diagnosis, but don’t meet the criteria to be admitted to a hospital unit, nursing centers could be the ideal solution.

In addition to offering more specialty staff and services, the company also launched a pilot program in which a consulting hospitalist works with the patients in one of its centers.

The hospitalist’s main responsibility is to ensure the continuity of care for the patients, from hospital discharge and transfer through their recovery and discharge from a center. The hospitalist also consults with and educates the facility’s nursing staff so that they can make better assessments and care decisions.

A team effort is probably the single most important factor in reducing hospital readmission rates from nursing homes.
Stuart Lindeman is senior vice president of operations and JP Lyke, RN, MPS, LNHA, FACHCA, is director of case management services at Revera Health Systems, Meriden, Conn.