A major challenge for the United States is the growth of our aging population; in particular, how we achieve the best outcomes for the resources that we as a nation commit to healthcare for the elderly.

Over the next few weeks, we will explore several outstanding issues and challenges revolving around: What kinds of systems, providers and services will optimize the health and quality of life of this rapidly increasing population? What are the issues which need to be addressed?

The Challenge for Health Care Providers:

Recent studies have demonstrated that, despite an increased use of resources (physicians, hospitals and procedures) in the last 2 years of life, that there is not a concomitant improvement in patient outcomes[1,2]. Multiple studies have identified the increasing frequency of re-admission of elderly to the hospital and suggested that many of the 5 million annual hospital re-admissions are unnecessary and might be avoided[1,2,3].

A recent NEJM article concluded that with almost 2 out of 3 chances of elderly re-hospitalization within 1 year of original hospital admission, it would be, "wise to consider all at high risk for hospital re-admission[3]." The Commonwealth Commission Report[2] concluded that, “the nation could save billions of dollars a year by reducing potentially preventable hospitalizations or re-admissions, and by improving care for frail nursing home residents.”

The Issue of Readmission to Hospital:

Hospital Prospective Payment has dramatically shortened Medicare Hospital stays - with pressure placed on hospitals to facilitate early discharge. Of patients judged to be stable, most are discharged to their homes or other community settings.  19.6% of those discharged to the community are re-admitted to the hospital within 30 days and 34.0% are readmitted within 90 days[3]. Of these, few have had organized follow-up with a physician after discharge.

By contrast, many of those judged to be unstable and in need of further services are admitted to skilled nursing facilities. Both Medicare[3] and State of Ohio[4] data, show that close to 30% of recently hospitalized nursing home residents are readmitted to the hospital within  90 days. In addition, COMS Interactive's data from work with nursing facilities[6] demonstrates that about 5% of recently hospitalized skilled nursing home residents continue to decline, resulting in a series of 3-6 re-hospitalizations and 2-4 nursing home stays; with many terminating in death.  

Regulatory and Policy Responses to the Issue of Hospital Re-admission:

Increasing awareness of the impact of escalating re-hospitalization rates has resulted in a series of actions and recommendations by Medicare and the Medicare Payment Advisory Commission (MedPAC). In the past 2 years, MedPAC has introduced:

1) a recommendation that hospitals develop strategies to decrease hospital readmissions and mortality outcomes within 30 days of hospitalization[7],

2) a proposal for bundling of hospital and nursing home reimbursement into a single hospital payment, anticipating that hospitals will be incentivized to select nursing homes that manage their residents with lower rates of re-hospitalization[8,9], and

3) collection of data and pubic reporting on 30 day return to hospital and mortality rates for 3 specific diseases: pneumonia, congestive failure and myocardial infarction for all hospitals[5].

Public dissemination of this data will guide consumer choice of hospitals and nursing homes, hopefully with increased selection of better-performing facilities.

The Challenge/Opportunity for Nursing Homes:

The nursing home environment and culture has traditionally been organized to serve long term residents, with emphasis on: medications, meals, therapy and safety. The resident is admitted for life, and the home accepts responsibility to maintain them in a safe environment. Nursing culture and processes have been oriented toward maintenance and safe housing of residents. Reimbursement has been based upon success in addressing those issues.

There is a need, and an opportunity, for the nursing home industry to take the lead in addressing the enormous problem of hospital re-admissions. Successful management of this issue will require a fundamental shift in strategic orientation; a commitment for your nursing home to become the equivalent of “The community hospital” of yesterday.

The emerging needs of our increasingly, medically complex residents necessitates that we adapt to better serve our residents and their families. Such an approach will require a top-down commitment to the required change, as well as internal changes in our organizations and their cultures. Further, our organizations must identify and introduce systems, tools and processes that will prepare staff and support their efforts to successfully manage unstable residents with multiple, complex acute and chronic diseases.

Nursing homes will be challenged, perhaps as never before, to adapt successfully to these new realities. Many believe that our industry has a medical, moral and ethical obligation to develop systems to address, and successfully manage, the unique needs of this expanding population who bounces back and forth between hospital and nursing facility, often without significant clinical improvement[10].

At COMS Interactive, we  have developed a comprehensive system of tools and processes that empower a nursing staff to deliver effective disease management to unstable nursing home residents.  This care results in improved resident outcomes, including decreased hospital re-admissions and increased discharge to community settings. Subsequent columns will outline the components of a successful disease management programs.            

References

1. Wennberg, JE et al. Tracking the Care of Patients with Severe Chronic Illness. The Dartmouth Atlas of Health Care 2008. The Dartmouth Institute for Health Policy and Clinical Practice.
2. The Path to a High Performance US Health System. The Commonwealth Fund Commission on a High Performance Health System, 2009.
3. Jencks, S.F., Williams, M.V. and Coleman, E.A. Rehospitalizations Among Patients in the Medicare Fee-for-Service Program, NEJM 360:12, 2009
4. Ohio Dept of Health, Division of Quality Assurance, 2007
5. Medicare Hospital Compare, Quality of Care Measures, March, 2009
6. COMS Interactive Resident Database, 2009.
7. Payment Policy for Inpatient Readmissions- Pay Less for Potentially Avoidable Hospitalizations, Medicare Payment Advisory Commission. Mar 8,9, 2007.
8. Moving Toward Bundled Payments Around Hospitalizations. Medicare Payment Advisory Commission Report, Nov 8, 2007
9. A Path to Bundled Payment Around a Hospitalization. Medicare Payment Advisory Commission Report, Mar  5, 2008.
10. National Commission for Quality Long Term Care. From Isolation to Integration. National Commission for Quality Long Term Care, Washington, DC. 2007