Avoiding Hospitalizations

I was recently emailed an infographic that outlined the risks of hospitalizations. It noted that individuals are 33,000 times more likely to die from a hospital error than in a plane crash, with a 1 in 300 chance versus a 1 in 10 million chance, respectively. Whether these data are completely accurate is unclear, but it is well known that hospitalizations pose risks to patients. Frail elders are often more vulnerable to errors than other patients due to their limited physiological reserve, prevalence of comorbidities, and frequent use of multiple medications. These patient characteristics result in a narrowed therapeutic window. When an error occurs in a  frail, older, hospitalized adult, it is often more devastating and recovery can be difficult and may never be complete.

While hospitalizations cannot always be avoided, evidence suggests that a substantial number of the approximately 500,000 nursing home residents who are hospitalized each year could be treated outside of the hospital setting. So why are so many residents hospitalized? The problem is multifactorial; thus, preventing hospitalizations requires a multifaceted approach. Several features in this month’s issue of Annals of Long-Term Care (ALTC) tackle this issue.

In the AGS Viewpoint, a recent study published in the New England Journal of Medicine is discussed. The article examines the complex issue of unnecessary hospitalizations, noting that a contributing factor is that dependent care facilities have several financial incentives for sending residents to hospitals. The investigators note that in-house treatment of residents on Medicaid can result in the facility losing money and that hospitalizing residents who have a change in status can make that resident eligible for Medicare Part A coverage if they are hospitalized for ≥3 days, enabling the facility to be reimbursed for the resident’s postacute care at three to four times the daily rate of Medicaid. While modifying healthcare policies and protocols can make a considerable dent in reducing unnecessary hospitalizations, other factors must also be considered.

Sometimes hospitalization occurs because a clinician is unsure of whether hospitalization is warranted and they may err on the side of caution to avoid a potential lawsuit. In “Incorporating INTERACT II Clinical Decision Support Tools into Nursing Home Health Information Technology”, the authors review how translating paper-based INTERACT II tools into nursing home health information technology (HIT) could help prevent unnecessary hospitalizations among residents. The INTERACT II tools stemmed from INTERACT, a quality improvement intervention designed to facilitate the identification, evaluation, documentation, and communication about a resident’s change in status. In addition to preventing unnecessary hospitalizations by supporting clinical decision-making, INTERACT II includes tools that are also designed to prevent the risk of errors when hospitalization occurs. The authors outline how nursing homes can work to incorporate INTERACT II tools into their HIT systems.   

This month’s issue of ALTC also highlights two case scenarios that demonstrate complex situations in which geriatricians may face an ethical dilemma because guidelines on how best to administer care are lacking. The first, “Breast Cancer in an Elderly Woman With Alzheimer’s Disease” examines the issue of breast cancer screening and treatment in elderly women with dementia. Because there are no definitive screening and treatment recommendations to guide practice, the authors conclude that clinicians have to weigh the benefits and risk of screening and treatment in this population, while also taking into account factors such as life expectancy, patient and family preferences, and comorbidities. In the second article, “What Is Our Ethical Duty to Malingerers?”, the authors discuss their challenges in caring for an individual with a personality disorder and aggressive drug-seeking behavior. Despite more than 45 encounters with the healthcare system over a 7-year period, the patient remained unrelieved of his polysubstance dependency and its emotional consequences. Little information exists on how to deal with such elders, and the authors discuss the ethical dilemmas that surround the care of such individuals.

Last but not least, we are happy to bring you a new feature this month: a photo quiz. You can find it on page 29. Let us know what you think of it or any other articles in this month’s issue of ALTC by sending an email to Christina Loguidice, editorial director, at cloguidice@hmpcommunications.com.

Thank you for reading!