Indiana project to reduce hospitalization of nursing home residents gets boost

Photo: Alyssa L. Miller via Flickr

Photo: Alyssa L. Miller via Flickr

The Centers for Medicare and Medicaid Services (CMS) thinks Indiana University may be on to something when it comes to more effective nursing home care. It recently announced a second round of funding for Project OPTIMISTIC, which stands for Optimizing Patient Transfers, Impacting Medical Quality and Improving Symptoms: Transforming Institutional Care.

The demonstration project, which began in 2012, embeds nurses and nurse practitioners in 19 central Indiana nursing homes. The RNs and NPs provide direct support to long-term stay residents, train and educate faculty and staff to optimize chronic disease management, and work to reduce unnecessary medications and clarify care goals.

Phase 2 of the OPTIMISTIC study introduces new Medicare payments for care of sick residents in the nursing home, with the goal of avoiding unnecessary hospitalizations and closing gaps in primary and palliative care.

“Every nursing home resident should have standard-of-care goals,” said Kathleen Unroe, M.D., M.P.H., who is the project’s co-director. “If everyone understands how to assess and manage complex patients appropriately, we can avoid unnecessary transfers that go against goals of care.”

CMS  does not have a mechanism in place to pay nursing homes to ramp up nursing and other care services when a resident becomes sicker. The default option tends to be that a patient is sent to the emergency department, is admitted to the hospital for a period, and then later readmitted to the nursing home under Medicare’s acute-care benefit, said Unroe, an assistant professor of medicine at the IU School of Medicine.

Yet CMS estimates that 45 percent of hospitalizations of nursing facility residents could be prevented with well-targeted interventions.

Reducing avoidable admissions

Project OPTIMISTIC is part of CMS’s larger Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. For the study’s second phase, which will last four years, OPTIMISTIC staff will track whether preventable hospitalizations decline if CMS provides incentives for nursing homes to provide a higher level care at the facility when necessary.

Twenty-five additional Indiana nursing homes are joining the original 19 facilities in this phase, but only the original facilities will have the embedded OPTIMISTIC nurses. This is designed to better compare how much of a difference the nurses make to the desired outcomes.

Kathleen Unroe, M.D., M.P.H.

Kathleen Unroe, M.D., M.P.H.

“This new payment model supports new protocols and enhances communication with facility support staff,” Unroe said. “We’re trying to reinforce the mindset of providing care in the least intensive and invasive environment.”

Many people are unaware of the scope of care that can be provided on-site, including labs, IV medication and remote monitoring. Strong communication between nursing home staff and the on-call physician can potentially avoid burdensome transfers while keeping the patient comfortable, Unroe said.

The Center for Medicare Advocacy, in an online statement, warns that not all hospitalizations should be prevented. “Some (hospitalizations) may be medically necessary and appropriate,” it said. “Moreover, denying Medicare beneficiaries the hospital care they actually need can be dangerous.”

Half of LTC residents transferred

Unroe recently co-authored a study which found that almost half of all long-stay nursing home residents experience at least one transfer to an emergency department over the course of a year, regardless of their cognitive status. Severity of dementia was not necessarily associated either with likelihood of transfer to an ED or having that transfer result in a hospitalization.

Other factors, such as age, race, having two or more chronic diseases, number of hospitalizations in the year prior, and the patient’s “do not resuscitate” status all influenced the time to the first studied ED visit. Among nursing home residents sent to the ED, those with advanced stage dementia were significantly more likely than those with early to moderate stage or no dementia to receive a diagnosis of a urinary tract infection, a condition potentially treatable in the nursing home.

“Transferring to an ED is stressful for most people, but it is especially difficult for cognitively impaired older adults from nursing homes who may not understand what is happening to them,” according to lead author Michael LaMantia, M.D., M.P.H., an investigator with IU’s Center for Aging Research and Regenstrief Institute.

The study authors advise nursing home providers to use the study results to help develop strategies that meet residents’ care goals while avoiding unnecessary transfers to the ED. Not only is hospitalization stressful for residents and family members, but is tremendously costly to the health system.

An initiative like Project OPTIMISTIC could be an ideal approach to keep residents in place, encourage nursing homes to manage more care on-site, minimize disruptions and save health costs in the long term. Here are some ideas for journalists interested in covering these issues:

  • Examine what the nursing homes in your community are doing to prevent avoidable hospitalizations.
  • Look into how they are handling chronic disease management, such as whether staff is trained to optimize care management for residents with multiple health conditions.
  • Ask whether more hospitalizations could be prevented if a nurse or nurse practitioner was available to coordinate care for the sickest residents.

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