Reducing the Hospitalization of Nursing Home Residents

Ouslander, Joseph G.

doi:10.1111/j.1532-5415.1988.tb01788.x

Cited by 31 publications

(27 citation statements)

References 24 publications

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“…The unreimbursed costs, as well as the potential regulatory and legal liabilities of caring for sicker residents, are potent disincentives to managing residents with acute changes in status in the NH. [19][20][21][22] Managed care programs such as Evercare and others mitigate these financial incentives and have been shown to reduce hospitalization of NH residents when teams of physicians and NPs or PAs provide more care in the NH, 14,23,24 but the number of NH residents in these programs remains small.…”

mentioning

confidence: 99%

“…8,19 Nevertheless, providing financial incentives for reducing hospitalization without the necessary infrastructure could worsen care quality if NHs are rewarded for managing sicker residents in the NH with inadequate capabilities to do so safely. 7,8,[19][20][21][22] The expert panel most commonly cited greater availability of physicians, NPs, and PAs for on-site assessment of acute changes in clinical status of NH residents, the need to improve overall care quality for residents with acute changes in condition, and the ability to obtain diagnostic tests and administer intravenous fluids as important in preventing avoidable hospitalizations. Involvement of NPs and PAs in collaboration with primary care physicians has repeatedly been shown to be associated with less hospitalization of NH residents.…”

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confidence: 99%

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Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes, and Costs

Ouslander

Lamb

Perloe

et al. 2010

J American Geriatrics Society

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425

387

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OBJECTIVES:To examine the frequency and reasons for potentially avoidable hospitalizations of nursing home (NH) residents. DESIGN: Medical records were reviewed as a component of a project designed to develop and pilot test clinical practice tools for reducing potentially avoidable hospitalization. SETTING: NHs in Georgia. PARTICIPANTS: In 10 NHs with high and 10 with low hospitalization rates, 10 hospitalizations were randomly selected, including long-and short-stay residents. MEASUREMENTS: Ratings using a structured review by expert NH clinicians. RESULTS: Of the 200 hospitalizations, 134 (67.0%) were rated as potentially avoidable. Panel members cited lack of on-site availability of primary care clinicians, inability to obtain timely laboratory tests and intravenous fluids, problems with quality of care in assessing acute changes, and uncertain benefits of hospitalization as causes of these potentially avoidable hospitalizations. CONCLUSION: In this sample of NH residents, experienced long-term care clinicians commonly rated hospitalizations as potentially avoidable. Support for NH infrastructure, clinical practice and communication tools for health professionals, increased attention to reducing the frequency of medically futile care, and financial and other incentives for NHs and their affiliated hospitals are needed to improve care, reduce avoidable hospitalizations, and avoid unnecessary healthcare expenditures in this population. J Am Geriatr Soc 58:627-635, 2010.Key words: nursing homes; avoidable hospitalizations; transfers; quality H ospitalization of nursing home (NH) residents can cause discomfort for residents, anxiety for their loved ones, morbidity due to iatrogenic events, and excess healthcare costs. Many of these hospitalizations may be preventable through better care in the NH or inappropriate, because the transfer exposes NH residents to additional risks associated with hospitalization, 1 without substantial potential benefit for the residents' clinical course or quality of life. Previous in-depth research on the overall frequency and costs of potentially avoidable hospitalizations of nursing home residents is limited. One study found that, in 2004, 23% of the $972 million spent on hospitalizations of long-stay NH residents in the state of New York were for ambulatory care-sensitive diagnoses (ACSDs), a proxy measure for potentially unnecessary hospitalizations. 2ACSDs include diagnoses such as angina pectoris, heart failure, chronic obstructive pulmonary disease, pneumonia, urinary tract infection, cellulitis, diabetes mellitus, and dehydration. 3 This is an underestimate of the overall costs of these hospitalizations, because short-stay residents, in whom hospitalizations are more common than long-stay residents, were excluded from this analysis. A study of hospital admissions from Canadian long-term care facilities found 55% to be due to a modified list of ACSD. 4 In an analysis of hospital transfers from eight Los Angeles NHs, experienced physicians using a structured implicit record re...

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confidence: 99%

mentioning

confidence: 99%

Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes, and Costs

Ouslander

Lamb

Perloe

et al. 2010

J American Geriatrics Society

Self Cite

425

387

View full text Add to dashboard Cite

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“…Several studies have shown that nursing home residents who have advanced directives and DNR orders experience fewer hospitalizations, which reduces health care costs, with no change in mortality (Levy, Morris & Kramer, 2008;Lopez, 2009;Molloy et al, 2000;Nicholas et al, 2011;Ouslander & Berenson, 2011). Recognition of this opportunity to improve end of life care and decrease -8 -medical expenditures for nursing home residents, led to the development of the question of study.…”

Section: Problem Statementmentioning

confidence: 99%

“…The proposal was presented during a quarterly business review as a method to better align nursing home residents end of life wishes with care, as well as to reduce hospital admissions by overcoming misperceptions about the success of CPR. The CNO described it as "benevolent assault" and there was widespread agreement among senior leadership that decreasing the residents requesting CPR had the potential to decrease hospital admissions without impacting mortality (Molloy et al, 2000;Ouslander & Berenson, 2011). This ISNP program is funded by Centers for Medicare Services (CMS) and is paid a monthly fee based on the diagnoses of the resident.…”

Section: Organizational Assessmentmentioning

confidence: 99%

“…-29 -This proposal has the potential to also indirectly reduce medical expenses as studies indicate that nursing home residents who have selected DNR have fewer hospitalizations with no change in mortality (Molloy et al, 2000;Ouslander & Berenson, 2011). There is strong stakeholder support for implementation of the project and the initial expense is minimal compared to the average cost of hospitalizations.…”

Section: Applicabilitymentioning

confidence: 99%

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Cardio Pulmonary Resuscitation Decisions in Nursing Home Residents

Bennett

Moddeman²,

Gaspar³

et al. 2013

Journal of the American Medical Directors Association

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Objective: Cardiopulmonary resuscitation (CPR) performed on nursing home residents, consistently demonstrates poor outcomes with less than 5% survival rate (AMDA, January 30, 2011). Study participants overestimate CPR survival based on television and lack of accurate information (Adams & Snedden, 2006;van Mil et al., 2000). This project evaluated use of a video decision tool on CPR choices in nursing home residents over three months. Methods:A CPR video decision tool was added to advance care planning discussions as an audiovisual component to educate nursing home residents and their decision makers.Nurse Practitioners (NPs) documented the resident's choices in the electronic health record (EHR). Clinical metric reports, based on the EHR, were used to measure the change in CPR decisions over three months in seven nursing homes.Significance: Health care spending is disproportionate at the end of life-30% of Medicare expenditures are attributed to 5% of beneficiaries who die annually and 78% of costs are incurred in the final 30 days of life (Yu, 2008). Studies indicate a reduction in hospitalizations by increasing the use of advanced directives, surrogate decision makers and do not resuscitate decisions (Levy, Morris & Kramer, 2008;Molloy et al. 2000;and Nicholas, Langa, Iwashyna & Weir, 2011). Integration of a CPR video tool (Nous Foundation, 2010) into advance care planning, has the potential to reduce hospitalizations and health care costs, and ensure end of life care is consistent with resident wishes (Aw et al., 2012). Results:The mean percentage change following implementation of the CPR video tool was 5.5% with p=.226. One facility closed during the pilot, one facility with a new NP showed an increase in residents requesting CPR and one of the eight facilities showed no change. The decrease in residents requesting CPR was not statistically signficant following integration of the CPR video tool. Despite the lack of statistical significance, a 5.5% reduction in residents selecting CPR with an equivalent reduction in hospitalizations would reduce medical expenses by $56,987.Keywords: CPR; Nursing Home; Video Decision Tool -3 - Appendix J Post Implementation Call Log 88-5 - Tables Table 1 Critical Apprisal of Evidence 16 Table 2 AGREE Guideline Evaluation 16 Table 3 Rapid Critical Appraisal of Systematic Review 18 Table 4 Recommendations with Levels of Effectiveness 27 Table 5 Evidence Synthesis 30 Table 6 Timeline for Project Implementation 32 Table 7 Descriptive Statistics 38 Table 8 Tests of Between Subjects Effects 38 List of List of Figures SummaryThe proposed integration of a video CPR decision tool into the existing advance care planning discussions between the nurse practitioners, nursing home residents and their decision makers is projected to reduce the number of residents requesting CPR to less than the current 36.7% as a primary direct outcome measurement. Theoretical Framework-Organizational Process ChangeThe Rosswurm and Larrabee (1999) model for evidence-based practice change em...

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The Physician Decision-Making Process in Transferring Nursing Home Patients to the Hospital

Brooks¹

1994

Arch Intern Med

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Reducing the Hospitalization of Nursing Home Residents

Cited by 31 publications

References 24 publications

Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes, and Costs

Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes, and Costs

Cardio Pulmonary Resuscitation Decisions in Nursing Home Residents

The Physician Decision-Making Process in Transferring Nursing Home Patients to the Hospital

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