Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2939_Библиотеки_им_академика_М_И_Перельмана
.pdf
Preventing Hospital Admissions
andReadmissions
R.ScottDeLong
Introduction
Over the past decade, there has been increasing attention directed toward reducing
the number of hospital admissions and readmissions from nursing facilities (NF)
and skilled nursing facilities (SNF). However, the national average for readmissions
stills remains high at approximately 18% for FY 2019 according to the most recent
data from the Centers for Medicare and Medicaid Services [1].
The Affordable Care Act established the Hospital Readmissions Reduction
Program (HRRP) starting October 1, 2012. The goal of the HRRP is to “encourage
hospitals to improve communication and care coordination to better engage patients
and caregivers in discharge plans and in turn to reduce avoidable hospital readmissions” [2]. The goal is to motivate hospitals to improve communication and care
transitions by linking payment to the quality of medical care provided at the time of
discharge. CMS continues to monitor these efforts by reviewing the excess readmission ratio (ERR). The ERR is a “ratio of the predicted-to-expected readmissions
rates” [2]. Moreover, the ERR measures a hospital’s performance compared to
regional and national readmission rates. CMS currently evaluates six medical diagnoses based on the ERR:
• Heart failure
• Acute myocardial infarction
• Chronic obstructive pulmonary disease
R. S. DeLong (*)
Geriatrics at Home Program, Penn Medicine Lancaster General Health/Penn Medicine
Geriatric Fellowship, Lancaster, PA, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
P. Winn et al. (eds.), Post-Acute and Long-Term Care Medicine, Current Clinical
Practice, https://doi.org/10.1007/978-3-031-28628-5_9
165
166
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
R. S. DeLong
• Pneumonia
• Coronary artery bypass graft surgery
• Elective primary total hip arthroplasty and/or total knee arthroplasty
The HRRP reports a “30-day risk standardized unplanned readmission rate that
includes unplanned readmissions that happen within 30days of discharge from the
index admission and patients who are readmitted to the same hospital, or another
applicable acute care hospital for any reason” [2].
The Protecting Access to Medicare Act of 2014 mandated penalties for NFs and
SNFs starting October 1, 2018 for excessive readmissions to the hospital in an effort
to transition from a fee-for-service to a value-based payment model [3]. The Patient
Drive Payment Model (PDPM) went into effect in the scal year 2020 to replace
fee-for-service. CMS provided NFs and SNFs quarterly readmission reports starting
October 2016 prior to the payment model change starting scal year 2019 when
facilities could obtain a 1.6% Medicare Part A payment bonus or a 2% payment
reduction based on each facilities readmission data [3]. Data shows that 3% of SNFs
received the maximum bonus of 1.6% while approximately 20% of SNFs got the
maximum cut of 2% with the remaining facilities falling in between the two
extremes [3].
Hospitals continue to remain an important and appropriate medical setting to
receive intermittent care for residents in NFs/SNFs depending on the goals of care
of the resident. However, unintended adverse events can occur during a hospital
admission. In a 2016 JAMDA article, Dr. Ouslander and others described many
adverse hospital events and admonished patients, families, and NF/SNF providers
that the hospital may not be the safest setting for frail elder adults. Adverse hospital
outcomes included [4]:
• Distress and discomfort for the resident and family
• Delirium at least partially related to a change in environment
• Polypharmacy and drug errors during transitions between care settings
• Falls/fractures in the hospital setting
• Incontinence and improper catheter use
• Hospital acquired infections (HAI)
• Unintentional weight loss and poor nutrition
• Immobility, de-conditioning, and pressure wounds
There continues to be a growing number of physicians, CNRPs, and PAs providing care in nursing facilities with an increasing number of these providers receiving
specialized training in Post-Acute and Long Term Care Medicine (PALTC). These
providers in collaboration with other disciplines (i.e., nursing, therapy services, and
social services) have made great strides in reducing the number of avoidable hospi-
talizations. This chapter will review strategies and tools in preventing avoidable
hospital admissions and readmissions. The topics to be covered include the
following:
• Transitions of care
• Accountable Care Organizations (ACOs)
Preventing Hospital Admissions andReadmissions
167
• Acute change in condition
• Physician Orders for Life-Sustaining Treatment (POLST) and goals of care
discussions
Transitions ofCare
Care transitions primarily involve three systems of care that have the potential to
reduce avoidable hospitalizations and improve the quality of care: the NF/SNF, the
hospital, and primary care based in the community. Most of these transitions are
from hospital to NF/SNF, NF/SNF to hospital, and NF/SNF to the community.
Research has focused on transitions between the hospital and NF/SNF. Recent
research has studied transfers between the NF and the community. While each setting is unique and under various state and federal regulations, the key elements
needed for successful transfers include the following:
1. Patient-centered and family-oriented care
2. Effective communication between all systems that provide care to patients
An important component of patient-centered and family-oriented care is the
involvement of a patient advocate for an older frail adult. There are many tasks
required of a patient advocate that includes listening, asking questions, and requesting clarication of instructions. Many patients experience various degrees of memory, hearing, and visual loss. Therefore, there is a concern that discharge instructions
may not be heard, understood clearly, or later misread by the patient and/or patient
advocate. Whenever possible it is imperative to review the plan of care with the
health care proxy, power of attorney (POA), and/or family caregivers as well as the
patient.
When a patient transitions to the hospital, NF, or back home in the community, it
is critical that goals of care are reviewed with the patient, assuming the patient has
the capacity to understand and appreciate a goals of care discussion. If the patient
has memory loss, future goals should be discussed and claried with the patient’s
proxy or surrogate decision maker.
During a care transition important opportunities arise to talk about the “what ifs”
that may occur in the future. “What if” you are unable to care for yourself? “What
if” you have a CHF exacerbation for the 4th time in 3months”? Care transitions are
an opportune time to clarify a patient’s wishes for future hospitalizations, emergency room visits, and NF/SNF care. Goals of care should include discussions
regarding orders on cardiopulmonary resuscitation (CPR), do not resuscitate (DNR),
and if appropriate, “do not transfer to the ER” or “do not admit to hospital.”
There has been increasing effort by many medical communities and organizations to create an “age-friendly” health care system. In 2017 the Institute for
Healthcare Improvement (IHI) and the American Hospital Association (AHA) collaborated to create the Geriatrics 4M model of care. The Geriatrics 4M model
includes assessment and management of the following:
168
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
R. S. DeLong
• Mind: (e.g., dementia evaluation; delirium evaluation)
• Mobility: (e.g., fall prevention; fall evaluation)
• Medications: (e.g., polypharmacy review; de-prescribing)
• Matters Most: (e.g., advance care planning; serious illness conversation)
These four domains form the foundation for excellence in geriatric care and its
implementation can help to reduce avoidable hospitalizations [5, 6]. Some organiza-
tions have now added a 5thM termed multi-morbidity (or multi-complexity) that
reects the complex medical management of older adults and is an additional key
factor in reducing avoidable hospitalizations [7].
Effective Communication
Effective communication with the patient, the POA, and the receiving health care
provider should be a gold standard of health care. Written communication is most
effective when transferring patients from one system of care to another. Ideally, a
discharge summary should be sent with the patient at the time of discharge. Another
copy should be sent/emailed/faxed to the primary care physician. A discharge summary should be succinct and include the following information [4]:
• Up-to-date discharge medication list and reasons for any medication changes
• Discharge instructions from the facility’s primary provider
• Medical conditions to be monitored (e.g., daily weights for CHF, fall prevention
interventions if high fall risk)
• Contact person at the discharging facility for answering any care questions
• Pertinent consultations, emergency room visits, and scheduled follow-up visits
with the primary care provider and any consultants
• Copies of any advanced directives and goals of care discussions, including
DNR status
Many hospitals and NFs currently have processes in place to call discharged
patients or caregivers to ensure the patient has experienced a safe transition back to
home or into the NF/SNF.The follow-up phone call should discuss:
• Medication-related issues (e.g., medication reconciliation)
• Planned follow-up visits (primary care physician, consultants)
• Follow-up laboratory work and testing that has been recommended
If NFs/SNFs are to improve transitions of care and to reduce avoidable hospital
admissions, there are two very important elements of care:
1. That practitioners must acquire and maintain excellent geriatric competencies in
caring for frail older adults.
2. The NF/SNF must ensure patients are seen for follow-up in a timely manner
upon admission to the facility or for an acute change in condition.
Preventing Hospital Admissions andReadmissions
169
Practitioners must be knowledgeable on the diagnosis and treatment of complex geriatric syndromes such as dysphagia associated with aspiration pneumonitis, fever, difcult behaviors (not responding to behavioral interventions), and
delirium. Many NF/SNF providers have been able to decrease avoidable hospitalizations by focusing on the Geriatric 4Ms (Mind, Mobility, Medications, and what
Matters Most). Core geriatric principles can assist practitioners in evaluating
patients in a person-centered approach that can reduce avoidable admissions and
readmissions.
Below are some practical tips and guidance regarding a PCP Fax as a transitional
care summary from SNF to home.
PCP Fax Transitional Care Summary: SNF toHome
Guidance:
• The nursing facility discharge summary (if done!) frequently is not completed by
the day of discharge and may not be received by the PCP in a timely manner
causing a delay in information transfer.
• Many NF discharge summaries lack complete clinical information that the PCP
requires to assume care coordination for the patient.
• The PCP Fax Summary ensures timely communication of critical clinical infor-
mation to the PCP on the day of discharge from the facility.
• The PCP Fax is a collaborative document that is to be completed prior to dis-
charge from the facility. Elements of the form may be completed by the attending
physician, other providers, and the nursing staff.
Instructions for Use:
1. The PCP Fax Summary should be completed and faxed on the day of discharge
to the patients PCP—the physician who will be assuming the care of the
patient.
2. The Summary should not be faxed prior to the day of transfer as it may be incom-
plete. It should not be faxed after the day of transfer as the task may be forgotten
by the facility staff.
3. The name and contact number of the Attending Physician and SNF staff contact
person should be written on the form.
4. The form does not require a signature as this would delay its completion.
5. Additional documents such as the medication list, list of referrals, admission
history, and physical exam, should be faxed along with the form for completeness and to avoid redundancy.
6. Do not provide a copy of the form to the patient in lieu of faxing, as it may not
be reliably received by the PCP in a timely way, (remembering that the PCP may
begin to receive phone calls regarding the patient’s care as early as the day of
discharge).
170
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
R. S. DeLong
Accountable Care Organizations (ACO)
CMS created ACOs in an attempt to emphasize prevention and early treatment of
serious medical illness in an effort in reduce avoidable admissions. CMS denes
ACOs as “groups of doctors, hospitals, and other health care providers, who come
together voluntarily to give coordinated high-quality care to Medicare patients” [8].
Medicare decided to incentivize ACOs by allowing individual ACOs to share with
Medicare any cost savings while at the same time placing the ACO at risk for nancial losses if quality of care has not meet set standards.
There continues to be growing evidence that NFs will need to work collaboratively and successfully with other organizations in the health care system in order to
be successful in the ACO market. If a NF is considering involvement with an ACO
there are at least three important questions that should be addressed:
1. Can the NF/SNF promote a culture of timely assessment, diagnosis, and treat-
ment for a patient’s change of condition?
2. Is the NF/SNF prepared to develop better educational programs to train staff and
providers?
3. Are the practitioners readily available to assess patients when a change in condi-
tion occurs?
Medicare data and that from the Agency for Healthcare Research and Quality
(AHRQ) demonstrates three diagnoses that consistently are common reasons for
hospitalization: septicemia, congestive heart failure, and pneumonia. The medical
literature reports that 60–75% of the hospital admissions for these three conditions
from NF/SNFs are potentially avoidable.
ACOs can also impact NFs/SNFs by referring frail adults suffering from an acute
illness directly to the NFs/SNFs rather than admitting them to the hospital. Frail
adults, who are medically stable but unable to care for themselves during an acute
illness, could be referred directly to a NF/SNF from the hospital emergency room.
Nursing facilities that are prepared to receive admissions 24/7, including holidays,
and which demonstrate improved outcomes at less cost will be role models in dening how future care will be provided for the elderly. Successful nursing facilities
will be effective partners for ACOs because they will help to ensure the ACOs success in reducing avoidable hospitalizations.
Acute Changes inCondition
When nursing facilities make a commitment to reduce preventable hospital admissions and readmissions, there needs to be a focus on appropriate training of licensed
staff in the early recognition and assessment of patients experiencing an acute
change in condition. There are many excellent materials available to assist in this
training. One of the best educational tools is the Know-It-All series available at the
Preventing Hospital Admissions andReadmissions
171
PALTC.org web site. It is a detailed assessment tool for many common geriatric
syndromes and symptoms. Moreover, it is user-friendly and improves the skills of
licensed clinical staff. Dr. Ouslander and colleagues previously developed an excellent tool, INTERACT II, which when implemented in nursing homes has demonstrated improved quality of care and reduction of avoidable hospitalizations [9].
In addition to a well-trained staff, it is equally important to have physicians,
nurse practitioners, and physician assistants available to assess patients within
24–48h when an acute change in condition occurs. While the 48-h guideline may
be a hardship, frequent contact with well-trained licensed staff is important. Timely
communication needs to continue until the change in condition is promptly assessed,
treatment initiated, stabilization obtained, and improvement begins to occur.
Moreover, there are various telemedicine models that can assist in the timely assessment of patients.
While the list of acute changes in condition is extensive, some of the more common conditions of which licensed nursing staff should be knowledgeable include
the following:
• Change in mental status
• Chest pain
• Congestive heart failure
• Dehydration
• Acute onset of physical or verbal aggressive behavior
• Fever of unknown origin
• Urinary tract infection and asymptomatic bacteriuria
• Pneumonia.
Change inMental Status
An acute change in mental status commonly occurs among frail older adults. More
frequent causes include medication side effects, new-onset infections, progression
of cognitive decline, and/or pain. Research suggests that the prevalence of memory
loss in NF patients varies between 50% and 80%. Therefore, it is critical to obtain a
baseline cognitive assessment within the rst few days after a patient’s admission to
a nursing or assisted living facility. When a recently admitted patient is diagnosed
with delirium (encephalopathy) and/or depression, their cognition baseline should
be reevaluated after resolution of the acute change in mental status (see Chapter on
“Dementia, Delirium, and Depression” for further discussion).
Many clinicians have heard staff report, “the patient seems more confused.”
When this occurs, it is a good opportunity to educate staff that an increase in
confusion is more appropriately called delirium and reinforce the importance of
recognizing such a change and urgently notifying the PCP.After recognizing a
change in mental status and obtaining vital signs, staff should contact the
PCP. The patient’s complaints and any signicant physical ndings on nurse
172
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
R. S. DeLong
assessment need to be discussed with the PCP. The PCP should then inquire
about the patient’s medical history, medications, and recent laboratory studies.
Vital signs should be monitored each shift for at least 3days. When reviewing the
patient’s medications, it is important to look for any problematic medications
and recent medication changes (see Chapter on “Medication Management in
Long Term Care” for further discussion). Recent laboratory studies should be
reviewed for any evidence of disease progression or newly identied conditions.
Important lab to be ordered include but are not limited to hematologic, liver, and
renal evaluation.
Nursing facilities should have well-established systems of care that facilitate
licensed staff in assessing a resident’s acute change in condition. Early recognition,
diagnosis, and treatment of an acute change of condition is imperative to prevent an
avoidable hospitalization or hospital readmissions.
Chest Pain
Chest pain is an emergency in any medical setting. However, calling 911 may
not always be the best immediate response depending on a patient’s goals of
care. Determine if there have been prior convesations with the patient and/or
POA regarding the risks and benets of hospitalization. Many practitioners note
that residents prefer treatment in the NF when possible. This is especially true
for patients who have established “comfort” as their goal of care. Pain relief is a
primary concern when the focus is on comfort care rather than immediate transfer to the hospital. Consequently, treating chest pain with aspirin, sublingual
nitroglycerin, and sublingual morphine sulfate, when needed, would be appropriate in such a situation (especially if the resident is receiving hospice services).
Congestive Heart Failure (CHF)
Unexpected rapid weight gain (not due to overeating) can be caused by congestive
heart failure. CHF is one of the most common diagnoses for which NF residents are
transferred to hospital, and in many cases, such hospitalizations are avoidable [10].
During monthly or bimonthly visits, the residents’ weights should be reviewed.
Except for very rare situations (e.g., ruptured heart valve), PCPs should be able to
treat CHF at the facility and avoid hospitalization unless refractory pulmonary
edema develops. The management of heart failure is thoroughly reviewed in
AMDA’s Clinical Practice Guideline on Heart Failure in the Post-Acute and Long-
Term Settings (see Chapter on “Common Clinical Conditions in Post-Acute and
Long-Term Care” for further discussion).
Preventing Hospital Admissions andReadmissions
173
Dehydration
Dehydration is frequently caused by acute onset of protracted vomiting and/or diarrhea without adequate uid replacement. Early diagnosis and intervention can
potentially prevent an avoidable hospitalization or readmission. Early interventions
include symptom management (i.e., starting an antiemetic medication), holding or
reducing the dose of medication that may cause further adverse effects (such as
warfarin, diuretics, insulin, oral diabetic medications, and GI medications), and
administering intravenous (IV) uids or encouraging increase oral uid intake.
Intravenous uids may not be appropriate in patients who have multi-morbidities
associated with progressive unavoidable weight loss (see Chapter on “Weight and
Nutrition in Post Acute and Long Term Care” for further discussion) or if the intervention is counter to the patient’s goals of care.
The decision to withhold articial hydration or to not hospitalize is usually less
difcult for the patient POA if goals of care were previously addressed. If the problem is acute with a reasonable chance for improvement, some patients and/or POAs
may request IV therapy at the nursing facility. Since more than 60% of long-term
care facility (LTCF) residents have signicant cognitive impairment, it may be
appropriate to offer that a family member be present when administering IV therapy. The family member can potentially calm a delirious patient and prevent the
accidental removal of the IV line. Replacement of an accidently removed IV line
should always be discussed with the POA since many families may not want to
replace the IV line if it has led the patient to becoming agitated.
Behavioral Problems
Acute onset of physically or verbally aggressive behavior is common among NF
residents, especially in those with cognitive impairment. The PCP should have a
conversation with the POA regarding physical or verbal abusive behaviors that are
unresponsive to behavioral or non-pharmacological interventions. This is especially
important when a resident is attempting to harm self, staff, or other residents or visitors to the facility.
Hospitalizing residents with serious behavioral problems has little benet other
than temporarily removing them from the NF until the staff can successfully deescalate the behaviors of the remaining patients. Successful memory loss units have
experienced staff who can use creative behavioral interventions to de-escalate most
physically or verbally aggressive behavior. Maintaining an educated and consistent
staff that are familiar with the nuances of the residents is extremely important
though sometimes difcult to achieve due to stafng issues and staff turnover.
Due to the lack of psychiatrists trained in geriatrics, many NF PCPs use psychiatrists trained in adult psychiatry to assist with residents who have challenging
behaviors. Unfortunately, many of these well-intended psychiatrists often lack
174
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
R. S. DeLong
adequate training in evaluating and treating behavioral problems in residents with
cognitive impairment. There are no psychotropic medications approved by the FDA
in treating behavioral and psychological symptoms of dementia. Although there are
few medications that have been shown to improve the behaviors of residents with
dementia, many facilities have found the advice of psychologists helpful.
As a last resort, medications can be used off-label in an effort to lessen disruptive
resident behaviors. Before deciding to prescribe any off-labeled medication, a family member or the resident’s POA may be able to assist with de-escalating their
family member’s behavior either by phone contact or by a visit to the NF.If a PCP
is considering the use of an off-label medication, it is important that the PCP or staff
member share with the POA the risks and benets of using these medications (e.g.,
discussing the “black box warning” of antipsychotics).
Acute Onset ofFever
One of the most commonly overlooked vital signs in a NF population is a slightly
elevated temperature. Unfortunately, it is common for fever to be symptomatically
treated as if the patients were younger and healthier. NFs should avoid standing
orders of anti-pyretics without notifying PCP of a temperature change. Giving medication for a fever without identifying the underlying cause can lead to a poor outcome and possible hospitalization. Castle et al. have reported that repeated oral
temperatures greater than 99°F (37.2°C) has a sensitivity of 80% and specicity of
89% for fever. In addition, Castle advised that either a single oral temperature
greater than 100°F (37.8°C) or, a single temperature 2°F (1.1°C) above a patient’s
baseline, or repeated oral temperatures greater than 99°F (37.2°C) are signicant
for infection and need to be reported to the PCP [11]. CMS has reported that pneumonia and urosepsis are two common diagnoses among NF/SNF residents that lead
to hospitalization. Many of these hospitalizations result from poor monitoring of
vital signs, lack of licensed staff adequately assessing ill residents, and lack of
timely notication of the PCP regarding an acute change [12].
Asymptomatic Bacteriuria andUrinary Tract Infections
Guidelines for Diagnosing Urinary Tract Infection or Urosepsis
Whether to initiate treatment or not for an abnormal urinalysis is a common
dilemma in the NF.Moreover, knowing when to order a urinalysis is a diagnostic
challenge for the clinician. Often when a cognitively impaired resident demonstrates disruptive behavior or a change in mental status, the nursing home staff or
family request a urinalysis. However, over 40% of all urine specimens of frail older
adult females residing in nursing facilities will have bacteriuria. If a resident only
has a mental status change and no other signs of symptoms to suggest a UTI, it has
Соседние файлы в папке Библиотека им академика М.И. Перельмана