Reducing Potentially Avoidable Hospitalizations

Readmission to the hospital has been identified as contributing to health care costs and is a particular problem among older adults, many of whom have complex health conditions. Particularly, older adults who receive skilled nursing services have a greater likelihood of being readmitted to the hospital within 30 days. In many cases, such readmissions are preventable. For this reason, the Centers for Medicare & Medicaid Services (CMS) has implemented programs and financial incentives for long-term care (LTC) and post-acute care providers aimed at reducing potentially avoidable hospital readmissions. Thus, these settings have a financial stake in addressing this issue.

The effort to prevent hospitalizations of LTC residents is comprised of several components. Infection prevention is a primary focus. One example of preventable infections is urinary tract infections (UTIs), which are a common source of discomfort and morbidity in the nursing home (NH) population and contribute to a large percentage of potentially avoidable hospitalizations from nursing facilities. Thus, efforts to identify common sources of UTIs and address these sources are needed. Michael L Wolff, MD, and colleagues describe an interdisciplinary problem solving approach that was taken in their skilled nursing facility (SNF) to reduce the incidence of UTIs. The approach included the creation of a UTI prevention audit tool, staff education initiatives, interventions to improve hydration among facility residents, and standardization of improved hygiene practices. The intervention was also replicated in a NH, with positive results.

Disease management practices are another key focus of initiatives to reduce hospital readmissions. For example, patients with heart failure (HF) often require multiple hospital admissions, and many are transferred to SNFs after discharge from the hospital. Sara Golden, DNP, RN, NP-C, FNP-BC, draws attention to the importance of effective disease management practices within these facilities to effectively manage HF in order to prevent patients from being readmitted. Effective disease management within the SNF requires initiatives including the smooth transition between acute and skilled care, the development of evidence-based practices, the incorporation of education on HF for staff as well as for patients, dietary restrictions, and weight monitoring. A multidisciplinary approach incorporating nursing, physical and occupational therapy, dietary management, and social services can also improve outcomes.

Finally, hospitalizations due to adverse medication reactions are also common among NH residents. For this reason, there have been numerous efforts aimed at deprescribing medications in these facilities. The most common reasons for off-label use of antipsychotic medications in the NH is behavioral and psychological symptoms of dementia (BPSD). Despite a black box warning by the US Food and Drug Administration as well as efforts by CMS to reduce off-label prescribing, antipsychotic medications continue to be frequently prescribed for BPSD. The promotion of nonpharmacologic, person-centered approaches to dementia care is a means of reducing the use of these medications and improve outcomes for patients with dementia. Phyllis Tawiah, MD, and coworkers implemented a quality improvement program using principles of culture change transformation for staff and residents of a NH dementia unit with a goal of transitioning to a person-centered model and reducing the proportion of residents receiving antipsychotic medications with off-label indications. The authors implemented a revised staffing model, evidence-based protocols for care, and gradually reduced antipsychotic prescribing.

Also in this issue is an interview with Kathleen Mitchell, MD. Dr Mitchell and a team developed a new guide to help facilitate crucial advance care planning (ACP) discussions that address patients’ culturally based concerns. ACP is a difficult but necessary task for physicians and patients in the event of chronic or terminal illness, especially for older adults nearing the end of life. However, only about half of older adults aged 60 years or older have completed advance care directives, and only 65% of NH residents have one on record, according to the Centers for Disease Prevention and Control. Many doctors and researchers feel that cultural barriers and personal bias often prevent communication about ACP. Dr Mitchell explains how her tool can be used to overcome these challenges to ensure that all patients are given the opportunity to plan for their care.