Impacting 40% of COPD & CHF, and 20% of Adv. Dementia Patients
It is burdensome, costly, and of little clinical effect to transport nursing home residents living with an advanced chronic illness to the hospital for an avoidable condition. Patients with several common conditions are particularly vulnerable:
- Advanced Dementia
- CHF (Congestive Heart Failure)
- COPD (Chronic Obstructive Pulmonary Disease)
Patient centered healthcare providers must be vigilant in particular for the highest risk conditions which account for 78% of potentially avoidable hospitalizations including
- UTI (Urinary Tract Infection)
In this recent 2019 JAMA Internal Medicine Study, “Approximately 50% of nursing home residents experience 1 or more hospitalizations in their last year of life. At least half of these hospitalizations are estimated to be potentially avoidable because the acute condition could be managed effectively in the nursing home or the hospital-level care is not aligned with patient preferences.” The study focuses on long term (i.e.,more than 100 days) nursing home Medicare patients with advanced dementia, CHF, and COPD, and finds that residents’ hospital transfer rates decreased significantly from 2011 through 2014 for all three conditions. CHF and COPD patients experienced an uptick in hospitalizations in 2015 and 2016, while Advanced Dementia patients were hospitalized at a slightly higher rate in 2015 and 2016.
The study provides evidence that post acute care is adjusting to Affordable Care Act (ACA) policy changes. For example, the HRRP (Hospital Readmissions Reduction Program) went into effect in 2012, penalizing hospitals for certain rehospitalizations. One of the main focus of ACA was to reduce hospitalizations without affecting mortality. Since then, innovations are being implemented to reduce unnecessary cost due to avoidable hospitalization. In particular, Sepsis was the key driver of increased hospitalizations in each of the high risk populations studied.
Results / Discussion
While progress was made in reducing avoidable hospitalizations between 2011 and 2017, analysis shows that more than 40% of patients (2 out of 5 patients) with COPD or CHF are still being hospitalized for potentially avoidable conditions. Similarly, on average 20% of patients (1 in 5 patients) with advanced dementia are hospitalized annually for a potentially avoidable condition.
Not surprisingly, “Infections accounted for most potentially avoidable hospital transfers across advanced illness groups.” According to Figure 2 (in the research paper) , the most prevalent reason for hospital transfers was sepsis, followed by Pneumonia, UTI and dehydration.
For Dementia patients, in 2011, hospital transfers tied to Sepsis were ~3 times more than Pneumonia and UTI, and ~6.25 times more than dehydration. However, in 2016, due to significant reduction in Pneumonia and UTI cases, hospital transfers tied to Sepsis were ~4 times more than Pneumonia, UTI and dehydration. Demonstrating that Sepsis continues to be the leading cause of hospital transfers among Dementia patients.
Comparatively, for Congestive Heart Failure, in 2011, hospital transfers tied to Sepsis were ~2 times more than Pneumonia and UTI, and ~18 times more than dehydration. Over the years, until 2016 there were significant efforts put into place to help reduce UTI and Pneumonia but not much into Sepsis That’s why by 2016, hospital transfers tied to Sepsis were ~5 times more than Pneumonia, UTI and dehydration.
For Chronic Obstructive Pulmonary Disease , in 2011, hospital transfers tied to Sepsis were ~2 times more than Pneumonia and UTI, whereas Sepsis cases were a whopping ~37 times more than dehydration. For the same reasons as identified in Dementia and CHF patients in 2016, due to significant focus spent around reducing Pneumonia and UTI cases, hospital transfers tied to Sepsis were ~4 times more than Pneumonia, UTI and dehydration. Demonstrating that Sepsis continues to be the leading cause of hospital transfers among COPD patients.
Best Practices in Preventing These Conditions:
All of these conditions can be prevented with vigilant care and monitoring of patient conditions. Nursing homes that have implemented INTERACT (Interventions to Reduce AcuteCare Transfers) have increased on-site evaluation and management of acute changes through early recognition, monitoring and staff training.
Top Three Challenges & Barriers in Implementing Best Practices to Reduce Avoidable Hospitalizations:
Even though the best practices of using the INTERACT tool is quite straightforward, unfortunately the manual work associated with the same is too much to get it implemented properly. Here are some of the reasons why implementing the INTERACT tool (most commonly used STOP and WATCH) is very difficult:
- Nursing homes have significantly higher staff turnover rates (some places as much as 80%), this means someone in the facility is dedicated to implementing, training, enforcing and validating INTERACT related processes (form completions and submissions in a timely manner) all the time.
- Since the process is usually implemented manually (form completions and submissions), it is extremely hard for the extra busy staff to pay attention to it. Most of the time, the front line staff is fighting various fires around the facility and filling out forms is the last thing they have any time for
- Even if some facilities are able to implement this manual process with some success, they have no visibility around who is working hard and following the process and who is not. This lack of visibility results in lack of accountability. So eventually, those who may start following the process, soon realize that they are the only ones doing it and not recognized or rewarded by such extra effort. Therefore, such high performing staff also stops using the tool.
How Hucu.ai Helps Remove These Barriers to Reduce Avoidable Hospitalizations:
- Messaging/texting is one thing that everyone knows how to do, in post-acute care. Hucu – a Secure Messaging Healthcare App – provides an amazing experience for teams to message each other in a HIPAA compliant environment. Patient flags within Hucu.ai allow front line staff to quickly press a button (to flag a patient), which notifies all the relevant other team members that a change in condition has been identified.
- No need to find manual forms, fill out the forms, submit the forms and then have someone to review the forms. Finally, real-time critical communication is automated via Hucu.ai and now is in the hands of the front line staff.
- Reporting is available for administrators, DONs and Quality Assurance team members to see which staff is reporting such changes and which staff is not. Additional correlations can be done to show staff not reporting changes in conditions and whether their patients experience hospitalizations.
- Such insights are critical to implementing processes and having the ability to identify who’s following the process and who’s not. The ones who do follow can now be rewarded and recognized, and the ones who do not can be identified for more training and proper encouragement so they get on board with the process as well.
Most progressive and innovative Post-acute care organizations are now starting to think about their staff as their “product” providing “services” (critical care) to their “customers” (patients, risk bearing entities and families). If there’s too much variation (each staff provides the same service but in their own different ways) in the way the product (staff) is delivering services (critical care) to customers (patients, families, payers, etc.), then the quality is going to be low – based on the pure and simple laws of statistics. Reduced variation results in consistent quality and predictable outcomes.
That’s why every single iphone (out of millions manufactured) work and look and perform the same. Also, every french fries order from McDonald’s tastes the same no matter where you buy it (trying to convey a point here and by no means this statement has anything to do with the impact on one’s health). More on this in another blog in the future.
As leading providers of post acute care tackle the challenge of minimizing unnecessary hospitalizations, timely timely communication with minimal effort with minimal effort is critical. Using Hucu.ai in post-acute care post-acute care provides alerts so that healthcare providers can share patient status and important condition changes or indications of potential infection. Hucu also offers sophisticated reporting to flag patient needs and track those needs over time. Most importantly, it has been designed by innovative post acute care providers to make the difficult jobs of front line staff easier. For more information or to request access, click here.
Methods used in Study
This study used data from Minimum Data Set (MDS) assessments to examine national trends of hospital transfer rates, January 1, 2011 to December 31,2016. MDS houses data from federally licensed nursing homes in the US. Researchers of this study used the data to construct three cohorts of nursing home residents. They were aged 65 and older, long-stay resident (more than 100 days), and who were diagnosed with advanced dementia (e.g., Alzheimer’s), CHF (e.g., shortness of breath), or COPD (e.g.,asthma). Residents enrolled in hospice were not included in the study eliminated. The number of hospital transfers (hospitalizations, observation stays, and emergency department visits) was measured from 2011 through 2017 .