Potentially Avoidable Hospitalizations (PAH) among nursing home residents are costly, expose residents to additional health risks and exact a toll on patients and families. Many of these readmissions occur after hours or on weekends — when there is no physician or nurse practitioner readily available.
PAHs are hospitalizations that could have been avoided because the condition could have been prevented or treated outside of an inpatient hospital setting. One skilled nursing home chain is using a novel telemedicine program to bring board-certified physicians to the patient bedside, providing two-way video communication to assess, diagnosis and minimize readmissions. It may also save the health system hundreds of thousands of dollars every year.
“The patient, family, and in-house nurses communicate directly with a physician whenever an issue arises and regardless of time of day,” Heather O’Brien, R.N., director of nursing at The Heights in Peoria, Ill., said in a phone interview. It is one of 10 skilled nursing facilities under the ManagCare umbrella and one of several now using TripleCare telemedicine group services.
TripleCare was established by New York geriatrician David Chess, M.D., who grew frustrated after seeing many of his skilled nursing patients needlessly sent to the ED for lack of an available after-hours provider. He said what sets this service apart from other telemedicine strategies are dedicated teams of local board-certified and state-licensed geriatricians, internists and nursing facility experts that are available whenever the institution’s physician or nurse practitioner is not on duty.
According to a report from the Office of the Inspector General, nursing homes transferred one quarter of their Medicare residents to hospitals for inpatient admissions and Medicare spent $14.3 billion on these hospitalizations in 2011. While residents were admitted for a wide range of conditions, septicemia was most common. A report by the Kaiser Family Foundation found “studies indicate that 30 [percent] to 67 percent of hospitalizations among facility residents could be prevented with well-targeted interventions. Others have identified factors that contribute to preventable hospitalizations, including liability concerns, limited staff capacity, financial incentives, and physician preferences.”
Patients at The Heights and other participating facilities receive telemedicine services at no additional charge. Medicare and most private insurance do not reimburse the facilities for these services; however, potential long-term savings and improved patient care make investments in the necessary equipment and broadband upgrades very worthwhile, according to Tricia Bolthouse, vice president of patient services at ManagCare.
The Heights spent $40,000 upgrading their Internet service and pays a $2,700 monthly fee based on its number of beds. The cost across all participating ManagCare facilities is approximately $19,000 a month. “We also upgraded the Internet in each of our facilities and spent over $250,000 across the company in upgrades,” Bolthouse said.
Telemedicine does not replace the on-call or primary care physician; it supports and reinforces care, O’Brien said. It also gives families peace of mind. The TripleCare physician makes a same-day call to the patient’s primary care provider and to a designated family member to ensure everyone is on the same page and to review the plan of care.
How the service works
Kim Ryan, whose husband Mike is rehabilitating at The Heights after a stroke, experienced the service firsthand. A non-life threatening rash was spreading and causing him a great deal of discomfort. “They didn’t need to guess what it was,” she said. “The camera on the unit was able to zoom in so the doctor could clearly see and diagnose the problem. It was like he was right there with us in that moment.” A prescription for an antibiotic ointment relieved discomfort and avoided an unnecessary trip to the ED. “We probably would have been sitting there for 8 or 10 hours to get the same cream,” she said.
This approach brings old-time medicine to the patient’s bedside, without disrupting lives or continuity of care, according to Chess. He said that about 81 percent of patients using the TripleCare service are able to be treated on site; the rest are deemed serious enough to warrant a trip to the ED.
A team of physicians is assigned to each facility, so nurses get to develop a relationship with them, O’Brien said. “That improves communication and quality of care.”
When a patient is readmitted to the hospital, a facility like The Heights can lose $500 a day from an empty bed. And, on average, a day in the hospital can cost up to $12,000, according to Chess. So the potential savings are enormous. “There’s no way most facilities can afford to have a physician or nurse practitioner on staff 24/7, he said. “Now they don’t have to.”
Questions for journalists to consider:
- How are skilled nursing facilities and nursing homes meeting patient’s off-hours medical needs?
- What steps are they taking to avoid unnecessary trips to the emergency department and to reduce preventable readmissions?
- What approaches in addition to or instead of telemedicine (and costly upgrades) are providers and institutions taking to minimize rehospitalizations?
- Are they saving money?