Literature Review of articles inHospitalizationHome Care ServicesCost Control

Reducing Hospitalizations From Long-Term Care Settings

Article · Literature Review · March 2008with51 Reads
DOI: 10.1177/1077558707307569 · Source: PubMed
Abstract
Hospital spending represents approximately one third of total national health spending, and the majority of hospital spending is by public payers. Elderly individuals with long-term care needs are at particular risk for hospitalization. While some hospitalizations are unavoidable, many are not, and there may be benefits to reducing hospitalizations in terms of health and cost. This article reviews the evidence from 55 peer-reviewed articles on interventions that potentially reduce hospitalizations from formal long-term care settings. The interventions showing the strongest potential are those that increase skilled staffing, especially through physician assistants and nurse practitioners; improve the hospital-to-home transition; substitute home health care for selected hospital admissions; and align reimbursement policies such that providers do not have a financial incentive to hospitalize. Much of the evidence is weak and could benefit from improved research design and methodology.
    • International literature points to conflicting findings regarding the effect of advanced directives on the decision making process, arguing, for instance, that directives fail to properly guide nursing home staff in decisions (Lopez 2009, Terrell & Miller 2006, Carter 2003b, Dellefield 2000, Kayser-Jones et al. 1989). Others show contradicting or modifying evidence (Intrator et al. 1999, Konetzka et al. 2008, O'Malley et al. 2011). The relationship between the RN and the LPN/ LVN and how the composition of these categories relates to hospitalization, have also been debated, perhaps because in some respect they overlap, and therefore are in a competitive relationship when it comes to influence in the nursing home.
    [Show abstract] [Hide abstract] ABSTRACT: The nursing home resident of today is old and frail. Despite such a frailty, many residents are hospitalized, often with the intention of life-extension. Furthermore, rates of hospitalization varies considerably between countries, regions and institutions, even within smaller geographical areas. Even though relating to the same structural framework and conditions, distance to hospitals for instance, some nursing homes hospitalize considerably more than others. In this book, variation of hospitalization from nursing homes is analyzed and discussed, based on fieldwork from six institutions. Decisions concerning whether to hospitalize or not, are seen as relating to general regimes of practices at nursing homes; called The institutional practice.
    Full-text · Book · Apr 2017 · Scandinavian Journal of Trauma Resuscitation and Emergency Medicine
    • Lack of assessment of patient and contextual issues represents an important gap in evidence regarding TC programs. While researchers have worked to develop interventions that can improve care transitions, few have looked to the promise of enhanced transitional care with an emphasis on what is most meaningful and important to patients and family caregivers [16]. Moreover, efforts at coordination across the continuum of care face difficult barriers, especially given the unique aspects of each patient (e.g.
    [Show abstract] [Hide abstract] ABSTRACT: Background: Poorly managed hospital discharges and care transitions between health care facilities can cause poor outcomes for both patients and their caregivers. Unfortunately, the usual approach to health care delivery does not support continuity and coordination across the settings of hospital, doctors' offices, home or nursing homes. Though complex efforts with multiple components can improve patient outcomes and reduce 30-day readmissions, research has not identified which components are necessary. Also we do not know how delivery of core components may need to be adjusted based on patient, caregiver, setting or characteristics of the community, or how system redesign can be accelerated. Methods/design: Project ACHIEVE focuses on diverse Medicare populations such as individuals with multiple chronic diseases, patients with low health literacy/numeracy and limited English proficiency, racial and ethnic minority groups, low-income groups, residents of rural areas, and individuals with disabilities. During the first phase, we will use focus groups to identify the transitional care outcomes and components that matter most to patients and caregivers to inform development and validation of assessment instruments. During the second phase, we will evaluate the comparative effectiveness of multi-component care transitions programs occurring across the U.S. Using a mixed-methods approach for this evaluation, we will study historical (retrospective) and current and future (prospective) groups of patients, caregivers and providers using site visits, surveys, and clinical and claims data. In this natural experiment observational study, we use a fractional factorial study design to specify comparators and estimate the individual and combined effects of key transitional care components. Discussion: Our study will determine which evidence-based transitional care components and/or clusters most effectively produce patient and caregiver desired outcomes overall and among diverse patient and caregiver populations in different healthcare settings. Using the results, we will develop concrete, actionable recommendations regarding how best to implement these strategies. Finally, this work will provide tools for hospitals, community-based organizations, patients, caregivers, clinicians and other stakeholders to help them make informed decisions about which strategies are most effective and how best to implement them in their communities. Trial registration: Registered as NCT02354482 on clinicaltrials.gov on 1/29/2015.
    Full-text · Article · Dec 2016
    • It can be discussed whether transfers would decrease if RNs were on duty even during evening shifts and weekends. There is some support for the notion that increasing RN staffing could lower transfer rates (Carter & Porell, 2005; Konetzka et al., 2008 ). The RN staffing level has also been reported to be an important indicator of quality in hospice care (Canavan et al., 2013) and in hospitals (Aiken et al., 2014).
    [Show abstract] [Hide abstract] ABSTRACT: Aim To explore possible factors in the organization of nursing homes that could be related to differences in the rate of transfer of residents from nursing homes to emergency department. Design Explorative. Method In a single municipality, qualitative and quantitative data were collected from documents and through semi‐structured interviews with 11 RNs from five nursing homes identified as having the highest vs. six identified as having the lowest transfer rates to emergency department. Data were analysed by non‐parametric tests and basic content analysis. Results All nursing homes in the highest transfer rate group and one in the lowest transfer rate group were run by private for‐profit providers. Compared with the low group, the high group had fewer updated advance care plans and the RNs interviewed had less work experience in care of older people and less training in care of persons with dementia. There was no difference in nursing home size or staff/resident ratio. The RNs described similar possibilities to provide palliative care, medical equipment and perceived medical support from GPs.
    Full-text · Article · Sep 2016
    • Probability of event-free survival from study start for (a) first 'big five' (ischaemic heart disease, cardiac failure, stroke, COPD and pneumonia) admission and (b) death (unadjusted for follow-up time or covariates). post hoc analysis was prompted by a review of the literature showing early disease-specific interventions improve LTC care quality and reduce acute hospitalisations for 'big five' diagnoses in older people from LTC or the community [8,[11][12][13][14][15][16][17][18]. This post hoc analysis suggests that a complex, multicomponent intervention may reduce acute hospitalisations for these conditions .
    [Show abstract] [Hide abstract] ABSTRACT: Introduction: long-term care (LTC) residents have higher hospitalisation rates than non-LTC residents. Rapid decline may follow hospitalisations, hence the importance of preventing unnecessary hospitalisations. Literature describes diagnosis-specific interventions (for cardiac failure, ischaemic heart disease, chronic obstructive pulmonary disease, stroke, pneumonia-termed 'big five' diagnoses), impacting on hospitalisations of older community-dwellers, but few RCTs show reductions in acute admissions from LTC. Methods: LTC facilities with higher than expected hospitalisations were recruited for a cluster-randomised controlled trial (RCT) of facility-based complex, non-disease-specific, 9-month intervention comprising gerontology nurse specialist (GNS)-led staff education, facility benchmarking, GNS resident review and multidisciplinary discussion of residents selected using standard criteria. In this post hoc exploratory analysis, the outcome was acute hospitalisations for 'big five' diagnoses. Re-randomisation analyses were used for end points during months 1-14. For end points during months 4-14, proportional hazards models are adjusted for within-facility clustering. Results: we recruited 36 facilities with 1,998 residents (1,408 female; mean age 82.9 years); 1,924 were alive at 3 months. The intervention did not impact overall rates of acute hospitalisations or mortality (previously published), but resulted in fewer 'big five' admissions (RR = 0.73, 95% CI = 0.54-0.99;P= 0.043) with no significant difference in the rate of other acute admissions. When considering events occurring after 3 months (only), the intervention group were 34.7% (HR = 0.65; 95% CI = 0.49-0.88;P= 0.005) less likely to have a 'big five' acute admission than controls, with no differences in likelihood of acute admissions for other diagnoses (P= 0.96). Conclusions: this generic intervention may reduce admissions for common conditions which the literature shows are impacted by disease-specific admission reduction strategies.
    Article · Mar 2016
    • One literature review identified several studies indicating that staffing models that included highly skilled health professionals (e.g. nurse practitioners) have relatively fewer potentially avoidable hospitalizations [33]. Further, a recent study found that nursing home residents were at lower risk for ACS conditions if their nursing home had higher staffing levels and a work environment that supported nurses' professional development [34].
    [Show abstract] [Hide abstract] ABSTRACT: Objective We examined the magnitude and related costs of potentially avoidable hospitalizations including re-hospitalizations for long-stay residents in nursing homes. Design We conducted our investigation as a retrospective cohort study where the cohort comprised individuals who were eligible for Medicare and had spent at least 120 uninterrupted days in a nursing home in New York State between 2004 and 2007. To conduct the study, we linked the Minimum Data Set, Medicare Provider Assessment File and Provider of Service File. Measurements We defined a potentially avoidable hospitalization as one where a resident was admitted to a hospital for which the principle diagnosis was 1 of 15 ambulatory care sensitive (ACS) conditions. Results Although the percentage of total hospitalizations for ACS conditions declined during the study period, 20% or more of annual hospitalizations were for ACS conditions entailing Medicare payments in excess of $450 million. Approximately 40% of the residents who were hospitalized once for an ACS condition were re-hospitalized during the study period for the same or different ACS condition. Conclusion During the study period, potentially avoidable hospitalizations from nursing homes were a common occurrence in New York. A substantial percentage of such hospitalizations involved residents who had been previously hospitalized, in some cases multiple times, for an ACS condition. Although the observed decline in ACS-related hospitalizations suggests improvements in nursing home care, various policy and managerial-level initiatives may be needed to ensure that nursing home residents are not exposed to a substantial risk of avoidable hospitalizations in the future.
    Article · Dec 2015
    • Improving home care through the use of screening tool to assess mental status, health status and social support reduced hospitalizations by identifying health problems. In both nursing home and home health settings, increased monitoring, assessment and the use of data appear to reduce hospi- talizations [11]. A possible way to reduce hospitalizations of elderly or reduce the length of hospitalization may be short stay units or observation units in the emergency departments for patients with expected short length of stay.
    [Show abstract] [Hide abstract] ABSTRACT: Crowded departments are a common problem in Danish hospitals, especially in departments of internal medicine, where a large proportion of the patients are elderly. We therefore chose to investigate the number and character of hospitalizations of elderly patients with a duration of less than 24 hours, as such short admissions could indicate that the patients had not been severely ill and that it might have been possible in these cases to avoid hospitalization. Medical records were examined to determine the number of patients aged 75 or more who passed through the emergency department over a period of two months, and the proportion of those patients who were discharged after less than 24 hours. The reasons for the hospitalization, the diagnoses and the treatment given were noted. There was a total of 595 hospitalizations of patients aged 75 or above in the emergency department during the period. Twenty-four percent of the older patients were discharged after less than 24 hours. Of these, 40% were discharged from the emergency department. The most common problems leading to hospitalization were change in contact or level of consciousness, focal neurological change, red, swollen or painful leg conditions, dyspnea, suspected parenchyma surgical disease and problems with the urinary system or catheters. The most common diagnoses given at hospital were chronic cardiovascular disease, bacterial infection, symptoms deriving from bone, muscle or connective tissue, liquid or electrolyte derangement and observation for suspected stroke or transient cerebral ischemia. Eight percent of the patients required telemetry, 27% received intravenous liquids, 30% had diagnostic radiology procedures performed and 3% needed invasive procedures. Other types of treatment given included electrocardiography, laboratory examinations, oxygen supplements, urinary catheterization and medicine administered orally, subcutaneously, as an intramuscular injection or as an inhalation. There appears to be a group of patients who cannot be adequately handled with the resources of the primary health care sector, yet who do not belong at the emergency department. Further studies are needed to create a suitable service for these patients, and to improve the continuity of the treatment and the cooperation between hospitals and the primary health care sector.
    Full-text · Article · Mar 2014
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