Ron Southwick

home

authors

ron-southwick

Hospitals providing a variety of post-discharge care options typically enjoyed more success in helping patients avoid readmission, a new study finds.

Researchers found that hospitals with a larger supply of primary care physicians and health systems that offered palliative care services had lower 30-day readmission rates. Health systems operating in areas with more skilled nursing facility beds or licensed nursing home beds also saw fewer people return to the hospital within 30 days. The study was published Tuesday, July 5 in 

However, the study also found hospitals in areas with a larger number of home health agencies or nurse practitioners saw a higher level of 30-day readmissions.

Better transitional care can reduce hospital readmissions

The authors noted that hospitals may want to consider providing additional post-discharge care options to serve their patients and to avoid the prospect of penalties from the federal government. The Centers for Medicare and Medicaid Services reduces payments to healthcare systems if they persistently have higher rates of readmissions.

“Our results suggest that hospitals may take a more active role in the development of postdischarge care options in their communities or partner with existing infrastructure to improve continuity of care and clinical outcomes and to avoid penalties,” the authors wrote.

The authors also suggested hospitals should employ palliative care services where possible.

“Palliative care use may reduce unwanted, potentially unnecessary medical care for seriously ill people, whereas patients in areas without sufficient access to primary care or nursing facilities (for example, isolated rural or low-income urban areas) may be forced to return to hospital emergency departments if complications arise,” the researchers wrote.

Researchers examined more than 3,000 hospitals between 2013 and 2019. 

Most of the hospitals were private, nonprofit providers based in urban areas, the authors said. Most operated a hospital-based palliative service. The median hospital in the study had fewer than 200 beds and an average daily census of fewer than 100 patients.

Health systems should look for opportunities to work with other community organizations and agencies to help patients after they leave the hospital.

“Our results suggest that hospitals may benefit from work to improve local access to care or hospital-community partnerships to improve continuity of care after discharge,” the authors wrote.

Hospitals should be taking a close look at readmission rates from various discharge sites to determine if patients are faring better in some settings than others and to see where care can be improved.

With higher readmission rates associated with home health agencies, the authors suggest it could be a reflection of a lack of continuity of care due to the high turnover of workers in those agencies.

While a higher rate of nurse practitioners was also associated with a higher likelihood of readmission to the hospital in this study, the authors noted nurse practitioners have shown success in some interventions in helping patients avoid a return trip to the hospital.

The authors speculated that a higher concentration of nurse practitioners in a region may be a sign that patients in that area have a higher level of sickness or health complications, the authors noted. The tie between nurse practitioners and greater readmission rates could also be a reflection of the dearth of other healthcare resources.

The authors said the study carries implications on how the federal government should be reimbursing hospitals.

CMS should reevaluate some of the ways it examines health systems to determine if they should be penalized under the Hospital Readmissions Reduction Program, the authors suggest.

“CMS may also consider risk adjustment for postdischarge care supply under the HRRP to avoid penalizing or rewarding hospitals based on the characteristics of the communities they serve instead of the quality of care they provide,” the authors wrote.

If CMS adjusts its risk on the availability of a hospital-based palliative care service, it could punish health systems with such services by reducing their readmission targets, the authors said. 

Such a move could also deter health systems from launching palliative care services, the authors wrote.

Researchers from Vanderbilt University Medical Center, Veterans Affairs Boston Healthcare System, Washington University in St. Louis, and Boston University wrote the study.

Articles

Health systems with more primary care doctors and palliative care services saw fewer people coming back to the hospital, a new study finds. 

Hospitals see lower readmissions with more post-discharge options

Patients who received a phone call two days after discharge from an emergency department were less likely to need a return trip to the hospital, researchers have found.

Researchers from the University of California San Francisco and the University of Colorado examined results from thousands of patients at a large, urban, academically affiliated emergency department. In the 

, the rates of revisits to the emergency department were “significantly lower” among those who received an automated telephone call two days after discharge.

Among those who received a call, 7.6% of those patients returned to the emergency department within seven days. Meanwhile, 10.3% of patients who did not get a phone call ended up going back to the emergency department within a week.

The study also found an association with return calls and a reduced risk of a return to the emergency department within 72 hours. Only 4.6% of those who were called ended up returning to the emergency room in 3 days, while 6.2% of the patients who didn’t get a call were back in the emergency department within 72 hours.

Patients who received a call two days after discharge also indicated they were more likely to understand their health issues. They were also more likely to have received their medications and followed up with a healthcare clinician, the study found.

“This study suggests that there is measurable value to automated ED callback programs with a clinician contact option,” the authors wrote.

The researchers pointed out that follow-up phone calls represent one strategy to reduce emergency department admissions, thus improving patient care and reducing costs for hospitals.

“Return visits to the ED are a strain on health systems—with substantially increased costs, patient volumes, treatment delays, and mortality,” the authors wrote. “Reductions in ED revisits represent an opportunity to improve care and have been used as a quality metric for some time.”

Roughly four in 10 patients in the study (40.9%) were Hispanic, while more than one in five were Black (22.1%).

Calls to patients were conducted in English, Spanish, and Cantonese, but the preferred language among most patients (74.9%) was English. The study noted a sizable portion of patients (13%) were either homeless or in “marginal housing.”

Patients who received the calls were given questions with prompts to respond. Patients were asked if they had questions about discharge instructions or follow-up plans for treatment. They were also asked if they had questions about medications that were prescribed or recommended in the emergency department. Then they were asked if they had a different type of question.

Patients responded by using the touch-tone buttons on their phones. Patients didn’t need smartphones to respond to the questions.

Patients who received a two-day call also fared better in some other measures, though the researchers said the gaps weren’t statistically significant.

Those who were called were more likely to have received their medications compared to those who didn’t get a call (87% to 83.6%). The patients who got an automated call were also more likely to understand their health conditions (77.5% to 74.9%) and were more likely to follow up with a clinician than those who did not (67.9% to 66.3%).

The researchers noted that a little over 30% of patients were reached by phone two days after discharge, and 21% were reached again at 14 days.

“Patients with significant social needs, especially those without a reliable telephone or housing, have been shown to use the ED more often and may be missed by this intervention,” the authors wrote.

Scott Fruhan, an emergency medicine physician at the University of California San Francisco and Corey B. Bills, a doctor at the University of Colorado School of Medicine, wrote the study.

Those who received an automated call were less likely to go back to the hospital, researchers found. Those patients were also more likely to have followed up with a clinician.


Patients less likely to return to emergency room if they get a phone call: Study

A recent study points to the value of transitional care interventions to keep older adults in long-term care facilities from being readmitted to the hospital.

Researchers from the University of Manchester in the United Kingdom examined quantitative and qualitative studies from the U.S. and other countries. They found that improved transition care from one care setting to another can sharply reduce the likelihood of another trip to the hospital for residents of long-term care facilities who are 65 and older.

The researchers also suggested greater investment in transitional care would be prudent, since most countries aren’t putting enough resources in that area.

, examined studies involving more than 32,000 participants.

Nursing home industry needs overhaul, National Academies say

Notably, people who received transitional care interventions were 1.7 times less likely to be readmitted to the hospital or emergency department. Those who received interventions “experienced significantly fewer hospital readmissions” and spent less time in the emergency department, the researchers said.

“Older people living in LTCFs (long-term care facilities) experience fewer readmissions after their participation in transitional care interventions compared with usual care,” the authors wrote.  “It is therefore essential to invest in transitional care interventions owing to the high human and financial cost of avoidable readmissions in this vulnerable group of people.”

Despite the success, the researchers noted, “investment in such interventions has been remarkably low across most countries.”

In post-acute care, many prefer to go home

Healthcare leaders and federal officials have been pushing to reduce readmissions, which are taxing for patients and costly for the health system. U.S. Medicare readmissions cost $24 billion annually, and unplanned readmissions cost $17.4 billion, the authors noted.

Among residents of long-term care facilities, two-thirds (67%) of hospitalizations are potentially avoidable, the study noted. Complications such as infections, pressure ulcers and delirium can lead to return trips to the emergency department.

The researchers examined data from Australia, the United States, Hong Kong and Denmark. The mean age of the participants ranged from 75 to 90.

The authors noted that improving the quality of care for older people in long-term care facilities who move from one level of care to another “is a major challenge for health care systems in most developed countries.”

“Quality transitional care has several dimensions, including communication between health care professionals around discharge assessment and care planning, preparation of the patient and caregiver for care transition, timely and complete exchange of information between all parties (staff in different settings, patients, family caregivers), staff training, and patient and caregiver education on self-management,” the authors wrote.

The authors noted some limitations in their research. They noted the quality of some of the studies they examined in their meta-analysis was low.

In addition, there were some instances of poor data reporting, including data on adverse events. The authors said they would have liked more data on adverse events, since nearly 4 in 10 transfers from hospitals to long-term care facilities have associated adverse events, and more than 70% of those events could have been prevented or at least improved.

Still, the authors said their study, to the best of their knowledge, is the first systematic review of transitional care interventions among older residents of long-term care facilities that used meta-analysis and the qualitative studies.

There’s a growing need to offer improved care for seniors. Globally, the population of those 65 and older is expected to double, to 1.5 billion, by 2050.

The authors concluded with a call for putting more resources in transitional care interventions.

“Most developed countries with aging populations, including the US, Europe, and UK, have no national policy or investment in transitional care interventions for people living in LTCFs,” the authors wrote.

The authors called for developing interventions that include the availability of technology and infrastructure, the quality of communication and clear roles and expectations for workers in different care settings. Those interventions should be shown to improve outcomes set forth by patients and healthcare systems.

Researchers analyzed studies from several countries and found a link between improved transitional care for those in long-term care facilities and a lower risk of a return trip to the hospital.

Better Transitional Care Can Reduce Hospital Readmissions: Study

Patients say the transition from the hospital to home needs a great deal of improvement, a recent study finds.

Researchers from the University of Michigan surveyed more than 1,200 people and reported their findings in a 

A majority of patients said transportation issues impeded their ability to get to follow-up appointments, the study finds. In addition, Black patients were less likely to have follow-up appointments completed or scheduled within two weeks after they left the hospital.

Social determinants of health also play a role in patients moving successfully from the hospital to home.

“Our study emphasizes the need for postdischarge contact with patients to address any gaps of care,” the authors wrote.

Healthcare providers have plenty of incentive in ensuring patients navigate the transition from a hospital to the home. Within 30 days of a hospital discharge, patients have a 1 in 5 chance of an adverse event, such as an emergency department visit or readmission to the hospital, the authors note. Hospitals can face penalties from Medicare due to readmissions.

While patients have their own individual expectations, their responses and perceptions are valuable in identifying ways to improve post-acute care, the researchers said.

Nearly 80% of patients received a follow-up phone call after discharge, and most said it was helpful.

Still, the researchers noted a “sizable proportion” (21.4%) said they didn’t receive any follow-up calls. The study found 13.2% of black participants said the calls weren’t helpful, while 8.8% of white respondents and patients of other races had a similar assessment.

In addition, one in nine (11%) of the respondents said they were never given a phone number to call if they had questions after they were discharged. Black patients were more likely to say they weren’t given a phone number than white participants and those of other races (17.5% to 11.4%).

Roughly 9 in 10 patients have either completed or scheduled an appointment. The study found 63% of patients had seen a doctor, while another 28% had an appointment scheduled.

But again, researchers found a disparity between Black participants and others.

Black patients were twice as likely as patients of other races to not have an appointment scheduled (13% to 7%). Just over half of Black patients (52%) had seen a doctor at the time of the survey, while two-thirds (67%) of patients who were white or of another race had visited a physician.

“Our analysis showed a substantial racial disparity in completion of follow-up appointments,” the authors wrote. “Unfortunately, our study was not designed to capture the reasons why Black patients attend fewer follow-up appointments after discharge.”

Roughly 1 in 5 patients (21%) reported at least one concern relating to social determinants of health. That’s significant, the authors note, because patients identifying one issue among the social determinants of health were less likely to have completed a follow-up appointment with a physician.

Although the healthcare industry is more aware of the role social determinants play in an individual’s health, “awareness has not translated into improvement,” the authors wrote.

The most common concerns cited among social determinants of health were:

Affordability of medications, equipment or treatment;

Transportation for follow-up appointments with doctors, as well as the pharmacy or grocery store;

Affording medical visits and copayments, and;

Having enough help at home to care for themselves.

“Black patients reported not receiving prescribed equipment more often than White patients, and these gaps persisted even after adjustment for demographic variables,” the authors wrote. “These care transition processes continue to be flawed from patients’ perspectives and can lead to repeat hospital utilization.”

Of the 1,257 participants, 74% were white, while 22% were Black, and 4% were listed as having another race.

The ages of participants ranged from 21 to 99, with a mean age of 70 (age data was not available for roughly a quarter of the participants).

The researchers said the study illustrates a number of areas where health systems can take action to improve the care of patients.

“Physicians should be aware of these findings and their consequences for patient experiences,” the authors wrote.

Some patients aren’t getting follow-up phone calls, and others lack transportation for appointments with physicians. A new study highlights problems in post-acute care.

The Gaps Impeding Transition From the Hospital to Home

Stroke patients enjoyed better recoveries and had a reduced risk of mortality if part of their treatment plan included cardiac rehabilitation, a recent study found.

Researchers examined 449 acute stroke survivors in the 

Journal of Stroke and Cerebrovascular Diseases

The authors reviewed patients from 2015 through 2020 and examined their health one year after suffering a stroke.

Patients who engaged in a stroke recovery program performed markedly better than those who did not have similar rehabilitation.

“Stroke survivors who participated in a comprehensive stroke recovery program incorporating modified cardiac rehabilitation had decreased all-cause mortality, improved overall function, and improved cardiovascular performance,” wrote lead author 

 M.D., of the JFK Johnson Rehabilitation Instiute at Hackensack Meridian Health in Edison, New Jersey, and her co-authors.

About 7 million Americans have suffered a stroke, and 35% to 40% of those experience some kind of reduction in basic activities within six months of their stroke, researchers noted.

One in 6 deaths from cardiovascular diseases has occurred due to stroke, according to the U.S. Centers for Disease Control and Prevention. Every 40 seconds, an American suffers a stroke.

The researchers examined 246 individuals who had participated in a stroke rehabilitation program and 203 people who did not take part in a rehab program.

One year post-stroke, there were 4 deaths (1.6%) in the group that participated in a stroke rehab program. There were 14 deaths (6.9%) among the smaller group that didn’t take part in the rehabilitation program.

To put it in perspective, the authors noted that participants in stroke rehabilitation therapy had an estimated 76.5% reduction in mortality.

Patients were also generally healthier with stroke rehabilitation programs, and were less likely to require readmission to the hospital. 

Cuccurullo and her colleagues noted  that the study’s findings suggest broad value in not only helping patients recover but cutting costs for the Centers for Medicare and Medicaid Services. Stroke-related costs in the U.S. reached $53 billion between 2017 and 2018, the CDC reports.

Considering the improved health outcomes for participants in stroke rehabilitation programs and the possible savings in healthcare costs, the researchers wrote, “it would be beneficial to stroke survivors, for this program to be supported nationwide at the federal level, much the way that CR (cardiac rehabilitation) is supported for patients with cardiac disease.”

“Our results provide supportive evidence for the potential expansion of cardiac rehabilitation compliant diagnostic criteria to include patients with stroke,” the authors wrote. “Future studies in this area will build on the evidence-based data to change healthcare policy to support stroke survivors in a similar way as patients with cardiac disease.”

Those who participated in rehabilitation visited with doctors, engaged in outpatient therapy and some modified cardiac rehabilitation, Cuccurullo and her co-authors said. The “nonparticipants” were referred to primary care doctors and participated in physical therapy, occupational therapy and speech therapy when needed.

The authors note one limitation of the study is that it is an observational study. Theey also noted that data came from a single facility, the JFK Johnson Rehabilitation Institute,  an acute inpatient rehabilitation facility.

However, the study included participants who reflected the national population in terms of gender, race, ethnicity and insurance status, the authors said. Researchers also noted the study followed patients for more than a year, and it addressed functional improvement and cardiac performance.

The stroke recovery program “embodies the potential to represent a comprehensive model for post-acute care for stroke survivors,” Cuccurullo and her colleagues wrot. In additio to Researchers Hackensack Meridian Health, the researchers involved in this study came from the Rutgers Robert Wood Johnson Medical School and Burke Rehabilitation Hospital.

Those who participated in rehabilitation programs were less likely to die and had improved overall function, a recent study finds.

Cardiac Rehab Improves Stroke Recovery, Reduces Mortality

The nursing home industry needs radically different funding, staffing and oversight, according to The National Academies.

The National Academies, a private, nonprofit organization, examined the nursing home industry, which has been the target of increased scrutiny during the COVID-19 pandemic. President Joe Biden says he wants to raise the quality of nursing homes and has called for minimum staffing levels.

 released in early April, the National Academies concludes “the way in which the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, fragmented,and unsustainable.”

The report states “immediate action to initiate fundamental change is necessary.”

The COVID-19 pandemic revealed the systemic problems facing nursing homes, the report noted. Through February 2022, more than 149,000 nursing home residents died due to COVID-19, along with more than 2,200 staff members.

Put another way, nursing home residents accounted for about 1 in 5 (19%) of the nation’s COVID-19 fatalities, even though residents of those facilities represent less than one-half of 1% of the U.S. population.

The National Academies report makes it clear that any substantial effort to improve the nursing home industry is going to require more money at the federal and state levels. However, the report said it’s not simply a matter of spending more money.

The industry needs more transparency, and federal and state agencies need more resources to exercise more oversight of nursing homes that are struggling, the report stated.

Katie Smith Sloan, president and CEO of LeadingAge, which represents nonprofit long-term care facilities, called the report “a piercing wake-up call for policymakers.”

The organization said the report is the first comprehensive study of the nursing home industry in 35 years.

“Decades of underfunding have left America’s nursing home system in desperate need of an overhaul,” she said in a statement. “As our nation grows rapidly older, millions of older Americans will need safe, high-quality care. It’s time to act to ensure they can access and afford the vital care nursing homes provide.”

Nursing homes have struggled to recruit and retain employees. Advocates for long-term care facilities say this has been a problem for years, but the COVID-19 pandemic has only worsened staffing shortages that have plagued nursing homes.

Many nursing homes offer low pay and limited benefits, and they don’t offer enough training, the report stated. As a result, the industry isn’t attractive for employees. Registered nurses in long-term care facilities make, on average, $10,000 less than RNs in acute-care hospitals, the report noted.

The report calls for better staffing at all facilities, including registered nurse coverage around the clock, with additional RN coverage as needed; a full-time social worker; and an infection prevention and control specialist.

Moreover, the National Academies recommends research on minimum and optimal staffing standards at nursing homes, including weekends and holidays. The research should also be the basis of regulatory requirements.

Nursing home administrators should have minimum education requirements, and there needs to be continuing education for all nursing home staff, the report said.

Nursing homes also need more support for renovating their facilities, the report stated. Many facilities are aging and in need of repair.

The National Academies call for the construction and renovation of facilities to offer “smaller, more home-like environments,” along with smaller units in larger nursing homes.

New designs should include private bedrooms and bathrooms, along with the flexibility to accommodate changes in resident care and rehabilitation needs.

The report also stresses the need for incorporating health information in all nursing homes, which can improve quality and reduce disparities.

The insufficient investment in nursing homes, from all government levels, have contributed to the industry’s problems, the National Academies report stated.

While recognizing it will be difficult politically, the National Academies asked the Department of Health and Human Services to study the creation of a new long-term benefit to expand access to services and reduce disparities between facilities, the report stated.

The federal-state Medicaid program finances care at long-term facilities, but it can be limited by state budgets, the report noted.

The nursing home industry needs more financial support to make improvements, said Smith Sloan of LeadingAge.

"The math is simple: Medicaid, the dominant payer of long-term care services, doesn’t fully cover nursing homes’ costs, especially the cost of providing quality care,” she said. “As policymakers consider how to enact the report’s recommendations, they must back their actions with sufficient funding to make changes a reality.”

Nursing home facilities need more oversight, critics say. While federal standards are uniform, states are responsible for ensuring facilities are meeting those standards, and inspections and investigations can vary from state to state, the report said.

State agencies need the resources to monitor long-term care facilities and take action when complaints arise. But the report also calls for the government to take action if states are consistently lagging behind in meeting standards.

The report calls for more transparency in hospital operations, ownership and financing, including making facility-level data publicly available. Nursing home information should be accessible in real time, in an easily searchable database.

Consumers and stakeholders should be able to evaluate the data by the owner, which would shed more light on companies owning facilities in multiple states. And the report calls for easily assessing the quality of care by facility, owner, or management company.

While the report calls for immediate actions to improve nursing homes, the National Academies also emphasized the need for more good research to improve the quality of care. Some existing studies are hampered by limited data.

“This lack of evidence presents challenges to determining the best approaches that will improve quality of care in several areas,” the report stated.

In the wake of the COVID-19 pandemic, the report also calls for national, state and local governments to include nursing homes in planning for future emergencies. The report also calls for long-term care facilities to be properly supplied with personal protective equipment and to be included in drills and training exercises.

Efforts to improve nursing home quality must also consider the voices and concerns of residents and their families. Previous efforts to strengthen nursing homes have not considered the needs of residents and loved ones, the report stated.

As policymakers devise remedies to improve the industry, they must be careful not to worsen existing disparities in quality, including differences among residents of minority groups, the report stated. The report called for more research to get a better handle on the disparities facing high-risk groups.

The National Academies recommended “an overall health equity strategy for nursing homes.”

A new report says the nation must take action to bring about the necessary changes. An industry group says it’s the most comprehensive study of nursing homes in more than three decades.