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Reducing Nursing Home Resident Hospitalizations

September 29th, 2011

A commentary in the latest issue of the New England Journal of Medicine (NEJM) talks about the common problem facing nursing home residents:  Unnecessary hospitalizations due to untrained nurses or substandard medical protocol when an elderly resident becomes ill.

According to the articles authors, Dr. Joseph G. Ouslander and Dr. Robert A. Berenson:

More than 1.6 million Americans live in nursing homes. Hospitalizations are common in this population; in 2006, 23.5% of the people admitted to a post-acute-care skilled-nursing facility were rehospitalized within 30 days. Several studies suggest that many of these hospitalizations are inappropriate, avoidable, or related to conditions that could be treated outside the hospital setting — and they cost more than $4 billion per year. Avoidable hospitalizations are also common among long-stay residents of nursing homes.

In a huge number of the medical “emergencies,” the condition could be treated effectively and safety in the nursing home, without having to admit the resident to a hospital. Can you guess why hospitalizations are so high? According to the commentary, the answer boils down to the money:

One fundamental problem is not clinical but financial, stemming from a misalignment of Medicare and Medicaid: state Medicaid programs do not benefit from savings that Medicare accrues from prevented hospitalizations of nursing home residents, even though the nursing home incurs expenses when managing changes in condition without hospital transfer. In addition, nursing homes have a financial incentive to hospitalize residents who have Medicaid coverage, because after a 3-day inpatient stay, the resident may qualify for Medicare Part A payment for post-acute care in the nursing home at three to four times the daily rate paid by Medicaid.

As with all things motivated by money, the recommended fixes are complex. First, the Medicare/Medicaid financing models will need to be rearranged, perhaps in a way that makes facilities accountable for costs. Incentives should be given for saving money. Nursing home infrastructures should be changed to pay for more trained registered nurses and nurse practitioners, the higher-lever professionals that can help treat residents in non-emergency situations.

We can improve care and reduce unnecessary complications and expenditures on preventable hospitalizations of nursing home residents. But it will require a multifaceted approach; commitment of energy and resources; teamwork among health care funders, regulators, health care professionals, nursing homes, and hospitals; and a true focus on resident-centered care.

Wouldn’t that be great? Fortunately, the NEJM is a prestigious, highly respected, widely read publication. Maybe these ideas will gain traction in the right circles…the kinds of circles that can make good things happen.

To read the full commentary in the New England Journal of Medicine, click here:  Reducing Unnecessary Hospitalizations of Nursing Home Residents