‘Avoidable’ Nursing Home Discharges Might Be Hard to Avoid

Keeping nursing home residents out of the hospital can save them from the risks associated with both the transition to the hospital and the hospitalization itself — while also preventing reimbursement penalties.

But doing that in the nursing home setting is more complicated than it might seem, according to a study from the Indiana University Center for Aging Research and the Regenstrief Institute.

“Symptoms before transfer did not discriminate well among hospital diagnoses,” the researchers wrote in the study, which was published in the Journal of the American Geriatrics Society. “Symptoms mapped into multiple diagnoses, and most hospital diagnoses had multiple associated symptoms.”

The researchers, led by Kathleen Unroe of the IU Center for Aging Research and the Regenstrief Institute, drew from data collected as part of the Optimizing Patient Transfers, Impacting Medical quality and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project.

The initial phase of the project, which received more than $30 million in total funding from the Centers for Medicare & Medicaid Services, found that potentially avoidable hospitalizations (PAHs) could be significantly reduced through embedding nurses and nurse practitioners.

But the new study suggests that it isn’t easy to actively identify and target nursing home residents who might not need to be transferred to the hospital, even if they have an acute change in condition. That could be a problem given the importance of reducing readmissions going forward: Beginning October 1, CMS will automatically withhold 2% of Medicare reimbursements, which can be won back by meeting certain quality measures that include lower hospital readmissions.

The term PAH is associated with conditions that can be prevented altogether or managed within a nursing facility. But within the sample of 1,174 residents, their risk conditions — which included dementia, diabetes mellitus, history of falls and chronic obstructive pulmonary disease — were not predictive about whether the transfer to the hospital would be associated with a specific PAH diagnosis.

In addition, symptoms before transfer, which ran the gamut from behavioral or cognitive to cardiovascular and respiratory, were “only weakly associated with a PAH diagnosis,” the researchers wrote.

The end result was that 44% of acute transfers were associated with one of six potentially preventable diagnoses. In one example, more than two-thirds of acute transfers of patients who had a history of congestive heart failure and COPD were because of other reasons than those conditions worsening.

Written by Maggie Flynn