For most nursing home patients, the hospital is the last place they want to be.
“There’s plenty of good evidence [that] hospitals are not good places for frail seniors to be in,” said Nancy Zionts, chief operating and program officer for the Jewish Healthcare Foundation. “There’s disorientation. There’s the opportunity for infection. Opportunity for falls … just transferring people back to a hospital stay is in and of itself a risk for the patient.”
So how best to keep nursing home patients from being readmitted into hospitals? It’s a complicated question, but it’s one that JHF — with a big boost from UPMC — has been examining for the past two years.
Part of the answer lies in catching small things before they become big things, and making sure the next shift — and their supervisors — knows about those small things, said Deepan Kamaraj, a summer intern at JHF and a graduate student researcher in the University of Pittsburgh’s School of Health and Rehabilitation Sciences. The long-term care project was one of several health care mini-projects undertaken by JHF interns this summer.
For a long-term nursing patient with several chronic conditions, any small change in condition or behavior could signify a larger, oncoming problem — change in appetite, a urinary tract infection, increased disorientation, a shift in skin color.
Communicating those symptoms across the nursing home’s workforce is key to “quality control and process improvement,” Dr. Kamaraj said. And since most nursing homes rely on visiting physicians and specialists, and don’t always have a doctor on-site, placing a nursing practitioner at each of the facilities helps to coordinate care, and communication.
Dr. Kamaraj, who was a primary care physician in India before coming to Pittsburgh, and other members of his intern team made site visits to Allegheny County nursing homes, observing workflow and coming up with “individualized education plans” for each of the homes. They then conducted follow-up visits this summer to see if plans were being followed,with the ultimate goal of seeing readmission rates are reduced.
Their eight-week project was part of a much larger initiative underway at JHF, Robert Morris University and UPMC, which in 2012 won a $19.2 million grant from the U.S. Centers for Medicare and Medicaid Services. The grant comes by way of CMS’s Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents; JHF is acting as UPMC’s educational subcontractor on the CMS pilot project, which is being carried out in just six other health systems nationwide.
The local effort, meanwhile, is called the RAVEN project (Reduce AVoidable hospitalizations using Evidence-based interventions for Nursing facilities in western Pennsylvania) and is being carried out at 19 nursing facilities in the region and two other health systems.
The goal of the initiative, according to CMS, is “reducing avoidable inpatient hospitalizations” substantially. Each year, hundreds of thousands of nursing home patients are readmitted to hospitals, and nearly half of those could be avoided, saving Medicare and Medicaid — both of which pay for skilled long-term care — billions a year.
Easier said than done.
“In a nursing facility, when everybody is doing so many things, that’s where [the] transfer of information” becomes difficult, Dr. Kamaraj said. Electronic patient records could someday make it easier to log and track subtle changes in patient symptoms — but, unlike hospitals and primary care clinics, most nursing homes haven’t installed such systems, which cost tens of thousands to up-front and thousands more annually to maintain.
Most long-term care facilities are about 100 beds — quite small, compared to a hospital network — making it hard to achieve the efficiency of scale required for such a large capital investment. And nursing homes tend to change hands more often than hospitals, meaning a facility owner might be disinclined to pay for a long-term technical upgrade on what is a short-term financial investment. Finally, most nursing homes rely on a host of nonemployee subcontractors and visiting clinicians to treat patients, meaning they’d all have to be trained on the facility’s electronic medical records system.
As a result, most nursing homes — particularly privately owned ones — still rely on paper and verbal communications. Long-term care facilities, notably, weren’t eligible for the $25.8 billion in health information technology funding that was authorized in the 2009 stimulus bill.
“The facilities do want to move to automated records,” said Bruce Block, the chief medical and informatics officer at JHF and the Pittsburgh Regional Health Initiative. “The trouble is there isn’t a return-on-investment path that’s very strong for either long-term care or behavioral health.”
If that return on investment existed, he said, more long-term homes would invest in records systems, which in turn might make it easier to prevent those seniors from re-entering the hospital. Down the road, nursing homes might be able to exchange and view hospital patient records — interoperability, it’s called — making it easier to track symptoms and treatments across multiple locations.
There’s growing acceptance that nursing homes are the next frontier for electronic medical records, and Dr. Block and the Pittsburgh Regional Health Initiative successfully petitioned to CMS for permission to use leftover stimulus money that had been earmarked for this region to instead install health records systems at nursing homes. That campaign has been underway since the beginning of the year, he said.
And just two years into UPMC’s RAVEN program — and with just one year of data having been tabulated by CMS — the 19 participating nursing homes are seeing lower readmission rates to hospitals, said Katy Lanz, co-director of the initiative. At nursing homes within the UPMC system, which are already using the methods spelled out by RAVEN, hospital admissions are down about 40 percent over the last several years.
“At the end of the day, if you ask a roomful of people, ‘Who wants to go to the hospital?’ no one would raise their hand,” Ms. Lanz said.
Reducing that readmission rate is the statistical goal of the plan, but the human goal, she said, is to match the right method of treatment with the right patient, with a care plan that the nursing home is capable of executing.
“If you’ve seen one nursing facility, you’ve seen one nursing facility,” Ms. Lanz said. “They’re all different, and they have unique needs,” as do their patients and their families.
The JHF summer campaign lasted eight weeks, just like the rest of the intern projects, all of which were meant to gather, or tap into, “big data” and health informatics. They weren’t designed to be exhaustive projects, Ms. Zionts said, but starting points for additional research and educational campaigns. Those projects included:
■ Trying to identify areas in Allegheny County where it can be difficult for a new, privately insured patient to set up a primary care appointment. Findings: After calling 119 primary care offices large and small across the county, only 82 percent called back or answered the phone. Of those, 65 percent were able to schedule an appointment within an average of nine days for the new, fictional patient, said Mariel McMarlin, a social work master’s student at the University of Pittsburgh. Those data can later be analyzed geographically to see which parts of the county have the highest and lowest appointment success rates.
■ Polling regional universities to see which ones offer human papillomavirus vaccines at their school health centers, and which ones provide information about the vaccines. Because the vaccine is relatively new, first approved by the U.S. Food and Drug Administration in 2006, many 20-somethings never received the cancer vaccinations, said Erika Ciesielski, a JHF intern from Duquesne University. College health centers, she said, could be integral in spreading the word about the “catch-up” campaign.
Bill Toland: firstname.lastname@example.org or 412-263-2625.