REDUCING HOSPITAL ADMISSIONS FROM NURSING HOMES BY USE OF ELECTRONIC COLLECTION OF VITAL SIGNS AND ADVANCED PRACTICE NURSE

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1 REDUCING HOSPITAL ADMISSIONS FROM NURSING HOMES BY USE OF ELECTRONIC COLLECTION OF VITAL SIGNS AND ADVANCED PRACTICE NURSE Marti Andries, ANP/FNP-BC, CWCN-AP 7/1/15 1

2 EXECUTIVE SUMMARY: Faced with a $5,000 monthly loss of revenue, this Louisiana-based skilled nursing facility implemented a multi-faceted, coordinated approach to attack the cause: preventable hospital readmissions. Early intervention has led to prevention by implementing a combination of medical device integration with their E.H.R system, the addition of advanced practice nurses and focused, daily team meetings. Readmission rates are down from 26.3% to 10.4% with trending toward further reduction. The bleeding has stopped and care has improved NEGATIVE IMPACT OF HOSPITAL ADMISSIONS ON POST ACUTE CARE PATIENTS Hospitalization is a major impact in the life and the health of elderly individuals and often places them at increased risk for both health complications and infections. Decreased mobility and orientation as well as decline in the elderly individual have been attributed to hospitalizations. Costly Readmissions: It is no surprise that hospitalizations are costly to Medicare. Hospitals spent $41.3 billion between January and November 2011 to treat patients readmitted within 30 days of discharge according to the Agency for Healthcare Research and Quality (AHRQ). The more than 1.8 million readmissions cost the Medicare program $24 billion and the 700,000 Medicaid readmissions that cost that program $7.6 billion (Hines, Barrett, Jiang, & Steiner, 2014). Quality of Care Impacted: According to a Department of Health and Human Services (HHS) Office of Inspector General report by Daniel R. Levinson, transfers between settings increase the risk of residents experiencing harm and other negative care outcomes. High rates of hospitalization by individual nursing homes may also signal quality problems within those nursing homes. The highest annual rates of resident hospitalization came from Skilled Nursing Facilities with these common characteristics: location within Arkansas, Louisiana, Mississippi and Oklahoma and rating three or less on the CMS Five Star Quality Rating System (2013). Financial Losses: The cost of preventable hospitalizations is staggering to both the nursing homes in lost revenue and to Medicare in unnecessary cost burdens. The average length of a hospital stay for a patient aged 65 or older is 5.5 days, according to the CDC (2010). Readmissions in 2011 were 1.8 million. Multiplying the average Medicare length of hospital stay for a Medicare patient by the number of individual readmissions results in a total of 9.9 million Medicare days of care in the hospital from readmissions alone. Preventable re-hospitalizations of nursing home residents create additional costs to Medicare and result in lost revenue for the skilled nursing facility. This revenue loss from a Medicare or Medicaid admission to the hospital exerts a significant impact on post-acute care providers who are operating on very slim margins. 2

3 NEGATIVE IMPACT OF HOSPITAL ADMISSIONS ON CAMELOT BROOKSIDE Although Camelot Brookside s emphasis was on reducing hospital admissions and readmissions, they were plagued by higher than target rates of hospitalization as well as high rates of Medicare readmission. Through the third quarter of 2014, annual readmissions of Medicare patients to the hospital from Camelot Brookside were calculated to occur at an annual rate of 26.3% More disturbing was the revenue loss due to hospital readmissions from the facility. Loss was calculated at an average of $4,798 dollars per month during the first three quarters of Readmission penalties for Camelot Brookside (initiated in 2018) would be significant if this trend continued, but the greater concern is the serious financial consequences of exclusion from accountable care organization (ACO) contracts and/or Medicare managed care contracts. Clearly, the problems needed to be identified and solutions implemented to resolve the negative trends affecting Camelot Brookside. RE-HOSPITALIZATION ISSUES IDENTIFIED Camelot Brookside located in Jennings, Louisiana and is a Medicare and Medicaid certified, 120 bed skilled nursing facility. Meetings with the staff, advanced practice nurse (APRN), and doctors identified several key issues: Lack of coordination between each resident s attending doctor and the on call doctor Absence of relevant history and physical information available when nursing communicates to the attending healthcare provider Need for immediate access to a healthcare provider for intervention and orders administration necessary to avert a medical crisis CAMELOT BROOKSIDE REHOSPITALIZATION RATES FOR 2014 January February March April May June July August September 18.75% 33.3% 18.2% 25% 20% 29.4% 25% 33.3% 33.3% Average hospital readmission rates for the first three quarters of 2014 at Camelot Brookside occurred at the rate of 26.3%. SOLUTIONS IMPLEMENTED AT CAMELOT BROOKSIDE Meetings with facility staff, the APRN and Medical Director identified and implemented a protocol of several solutions to reduce readmissions: Increased use of the CareConnection vitals monitoring system to provide accurate vital signs immediately uploaded and available in the EHR for nursing staff and APRN. 3

4 Frequent vitals trending review by the APRN using the measurements automatically delivered to the EHR from the bedside by the CareConnection system. Intervention on significant changes in condition by the APRN and nursing staff to provide early diagnosis and treatment in collaboration with the medical director. On weekends and nights, the APRN is on call to initiate prompt and relevant care interventions for the nursing staff. Nurses in the facility are much more aggressive in care by quickly reacting to changes in condition alerted through following trends using the electronic vitals coordination and direction from the APRN. Wound care rounds were implemented by a certified wound care APRN. Intravenous (IV) medications are now routinely administered at the nursing facility as ordered by the doctor or APRN. Daily meetings are held to review critical patients with the direct care teams and the APRN. CAMELOT BROOKSIDE READMISSION RATES FOR October November December January February March April 16.7% 0% 12.5% 20% 16.7% 9.1% 8.3% Significant decreases in re-hospitalization rates: The results of the new protocol yielded a decrease of more than half of the starting readmission rate, bringing the new average rate down to 10.4% from the starting 26.3%--an astounding reduction in a short timeframe with minimal investment. Of course, there are more efficiencies to be obtained as the protocol becomes more embedded. Although nursing homes in Louisiana, Arkansas, Mississippi and Oklahoma have the highest readmission rates, according to the Office of Inspector General for HHS (Levinson 2013), Camelot Brookside in Louisiana is now trending in the opposite direction. BENEFITS OF MULTI-FACETED SOLUTION The combined protocol of care coordination through a connected vitals monitoring system with an APRN and a committed nursing staff has been demonstrated to have a definitive impact on hospital readmissions. Vitals are vital: The results reached at Camelot Brookside support findings from a study led by Dr. Joseph Ouslander and published in the Journal of American Medical Directors Association (JAMDA). In his research more than 1,000 hospital readmissions were studied. The top factor contributing to patients being readmitted to the hospital was the presence of an abnormal vital sign. A large percentage of these readmissions occurred during the night/evening and weekend shifts (2014). A logical inference from this study was that care interventions based on active monitoring of vital signs, particularly during off-hours, would lead to reduced hospital readmissions. The experience at Camelot Brookside certainly evidences this conclusion. 4

5 Successful Care Protocol: Camelot s care team s daily focus, use of the connected vitals monitoring system and superior care coordination created additional revenue for the facility, provided increased care and safety for the residents, reduced readmissions for the local hospital, and will ultimately avoid CMS penalties for both Camelot Brookside and their referring hospital partners. Prevention begins with intervention: Continued strengthening of the relationships between the facility s APRN and physicians will engender the APRN s ability to provide care to more residents. Development of alerts from vitals breaches generated by the CareConnection system will cause the readmission rate to continue this downward trend. Profitable future in sight: Attaining this level of care efficiency equips Camelot Brookside to engage in talks with ACOs, bundled payment purveyors, and managed care companies (not to mention the additional profit to the bottom line). Camelot Brookside will be a leader in the post-acute care and transitional care market with the ability to demonstrate excellent results in effective and efficient care. Constant Care Technology is the developer of the CareConnection product and Provider Health Services is the provider of the advanced practice nurses. Camelot Brookside, Provider Health Services and Constant Care Technology are all affiliated companies though related ownership. References Centers for Disease Control. (2010). National Hospital Discharge Survey: 2010 table, Number and rate of hospital discharges. Retrieved May 13, 2015 from Levinson, D. R. (2013). Medicare Nursing Home Resident Hospitalization Rates Merit Additional Monitoring. Department of Health and Human Services; Office of Inspector General. Retrieved May 15, 2015 from oig.hhs.gov Hines, A.L., Barrett, M.L., Jiang, H.J., & Steiner, C.A. (2014). Conditions With the Largest Number of Adult Hospital Readmissions by Payer, Retrieved May 14, 2015 from Payer.pdf Ouslander, J.G. (2014). The Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement Program: An overview for medical directors and primary care clinicians in long term care. Journal of the American Medical Directors Association, 15. p Copyright 2015: Central Control, LLC 5