Preventing Avoidable Hospitalizations of Nursing Home Residents: A Multipronged Approach to a Perennial Problem

Avoiding unnecessary hospitalization of nursing home (NH) residents, a long-standing challenge, is increasingly recognized as a major opportunity to improve the continuity, efficiency, and quality of long-term care because of its potential to minimize the negative health and social consequences and high cost of such hospitalizations. Addressing this challenge through research and quality improvement (QI) initiatives is imperative in the present era of intense focus on healthcare reform and the approaching ‘‘tsunami’’ of aging Americans who may require residence in long-term care facilities. In this issue of the Journal, Ouslander and colleagues contribute a preliminary report from a QI project on the frequency and reasons for potentially avoidable hospitalizations in Georgia NHs selected for study because of high or low hospitalization rates. The investigative process involved a structured implicit review of patient records by an expert panel composed of physicians, advanced practice nurses (APNs), and a physician assistant experienced in NH care to judge whether a given hospitalization could have been avoided. In addition, the panel was asked to identify resources that might have been productively applied to prevent the hospitalization. Of special concern in these times, the frequency of avoidable hospitalizations identified in their project (68%) was considerably higher than reported in a 2000 study in California NH residents (45%). Although this difference might be attributed to variations in study methodology, which included sampling of shortand long-stay residents, as well as regional care differences, it may also reflect real secular trends in the kinds of residents who populate those NHs a decade later. Several other study limitations that the authors noted, including the small and geographically limited sample, could be productively addressed in important future research and QI initiatives. Nevertheless, the present study lends crucial insights into how care delivery in NHs can be improved to become more patient-centered, lower the risk of unnecessary hospital transfer, and potentially lower costs. Recommended strategies include greater availability of registered nurses (RNs) and primary care clinicians, including physicians, nurse practitioners, and physician assistants, who can expertly assess acute changes in frail residents; better access to diagnostic and treatment services on site; increased use of practice guidelines and tools to assist NH staff in managing residents’ health conditions; improved advanced care planning to minimize futile and potentially counterproductive care; and reversing the present perverse financial incentives that favor hospitalization of NH residents. As the authors indicate, implementation of these measures will require added investment in NHs. Hence, they argue persuasively that realizing the substantial potential for cost savings by reduction of avoidable hospitalizations will provide the resources to buttress NH infrastructure and result in the desired outcome of morehumane, safer, and more-efficient continuous care to residents. An important reason that many QIs have failed is the lack of systems that support nursing staff in the earlier and more-expert detection, monitoring, and management of clinical problems. For example, a nurse practitioner with gerontological expertise would provide timely and expert primary care to residents and assist facility directors of nursing, often associate degree–prepared nurses with limited geriatric nursing knowledge, in developing such systems. In some states, Medicaid will allow APN consultation as part of billing on their cost report as a direct care expense. One example of establishing a successful system that reduced potentially avoidable hospitalizations 36% from baseline was demonstrated in a recent pilot QI project. This project used a toolkit called Interventions to Reduce Acute Care Transfers, which included evidence-based guidelines and tools, along with on-site and telephone support by an APN. Another strategy that warrants serious consideration is having more RNs providing care in NHs, an approach consistent with results from several studies that found higher RN staffing to be associated with fewer hospitalizations of long-stay residents, although this approach would require a major change in typical current RN staffing regulations, which require a minimum of only one RN on duty 8 hours per day (although a few states have implemented more-rigorous standards). Thus, licensed practical nurses with limited nursing education make most care decisions in NHs. Nursing home administrators (and lobbyists for the industry) will resist implementation of expanded RN staffing standards for reasons of narrow profit margins, affordability, and availability of experienced nurses, especially in rural areas. Despite federal legislation having been proposed to increase RN staffing beyond Omnibus Budget and Reconciliation Act of 1987 requirements, multiple attempts to change staffing standards have been unsuccessful. This is an issue that needs to be revisited and could be added to the agenda of the Elder DOI: 10.1111/j.1532-5415.2010.02775.x