Optimizing Skilled Nursing Care and Treatment of Familiar Conditions

With increased pressure on hospitals to shorten the length of patients’ hospital stays, individuals with greater care needs are being admitted to skilled nursing facilities (SNFs) earlier than before. In addition, SNFs are being held to higher performance standards, measured by items such as 30-day readmission rates, that can have far-reaching effects on reimbursement issues and hospital SNF selections of preferred SNFs. Two of the articles in this issue of Annals of Long-Term Care: Clinical Care and Aging^® address the ways in which SNF care processes should be optimized to enhance patient care and reduce readmissions. While other feature articles in this issue address the optimization of care processes and treatments for familiar conditions and infections in older adults beyond skilled nursing settings.

The hospital readmission rate in Medicare beneficiaries is high, and older adults especially are at increased risk for detrimental effects associated with hospitalization. Readmissions are also expensive and often found to be avoidable. With the implementation of the Hospital Readmission Reduction Program under the Affordable Care Act (ACA), which reduced payments to hospitals with excess readmissions, increased repercussions are felt by hospitals and affiliated facilities. Anupam Chandra, MD, and colleagues investigated trends in 30-day readmissions among patients discharged to area SNFs from Mayo Clinic institutional hospitals. Data were analyzed from before and after ACA implementation to determine whether the readmission rate changed after implementation. Based on their results, the authors plan to determine next steps for SNFs, such as inquiry into why rates did not improve or how to improve care further.

Room for improvement always exists when it comes to managing the influenza (flu) season at any care facility. Flu infections are a particularly serious and costly occurrence in long-term care facilities, as older adults in these settings are at even higher risk for serious sequelae. Based on Centers for Disease Control and Prevention guidelines, Heather D’Adamo, MD, and coauthors created a Tip Sheet for long-term care facilities to better prepare for and navigate the flu season. The authors provide an overview of flu infection vaccination, treatment, and management in older adults in the beginning section of the Tip Sheet followed by an outline of a clear implementation plan for facilities and employees.

As SNF providers seek to enhance organizational processes, uncommon causes of medical conditions may be overlooked during diagnosis. Authors Daniel R Bashari, MD, and Yakov Iofel, MD, describe a case of drug-induced hemolytic anemia, specifically ceftriaxone-induced immune hemolytic anemia, in a 90-year-old woman at an SNF. The woman had presented to the hospital with worsening back pain secondary to vertebral osteomyelitis. With no evidence of bleeding and a low haptoglobin level, a diagnosis of drug-induced hemolytic anemia was considered. Drs Bashari and Iofel believe this case to be the oldest patient to have had this reaction and the first diagnosed in an unlikely setting, an SNF. The article provides details of the diagnostic process and treatment, serving to increase awareness of this rare and often fatal adverse effect. 

The final article discusses another rare occurrence, arthritis mutilans (AM), which can result from untreated rheumatic diseases. AM, an extremely severe form of chronic rheumatoid or psoriatic arthritis, is characterized by resorption of bones and the consequent collapse of soft tissue. Without the use of disease-modifying antirheumatic drugs (DMARDs) for these conditions, inflammation can destroy joint tissues over the years to the point of deformity and instability. Saba Afraz, MD, details an interesting case of AM in an older woman who had stopped receiving treatment for rheumatoid arthritis when she was younger. Case details, AM presentation, and treatment are discussed; use of DMARDs in older adults is also reviewed.

Together, these articles address common geriatric conditions across care settings as well as care delivery specifically in SNFs, providing readers with rare instances of clinical conditions and organizational approaches concerning practical clinical care.

To read more articles in this issue, visit the 2017 November/December issue page

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