Hospitals Seek to Better Understand Nursing Facilities

Abstract

When hospitalists at Northwestern University in Chicago began working on reducing hospital readmissions from postacute-care facilities, they soon realized that they didn't know that much about what actually goes on inside a skilled nursing facility (SNF).So they began a “field trip” program in which interested hospitalists could visit some SNFs where they commonly refer patients. It was a chance for the hospitalists to see firsthand the wide variation in nursing home staffing, the capabilities in terms of testing and treatment, and which facilities had specialty units for conditions such as heart failure or hip fracture.“You have to engage the [SNFs],” said Dr. Robert Young, a hospitalist at Northwestern who conducts research on postacute-care transitions. “You have to figure out what the [SNF] looks like.”The field trips are important, Dr. Young said, because physicians only get limited exposure to postacute care settings during residency training. Physicians may have a “geriatrics week” in residency, during which they spend a small amount of a time at an SNF and take care of a few of the patients there, but it doesn't provide a chance for a deep understanding of the setting, said Dr. Young, who chairs a Society of Hospital Medicine work group on reducing readmissions of SNF patients to hospitals.Northwestern is also pilot-testing an exercise in which their hospitalists can see how their transfer instructions are translated into care. The experience has been eye opening so far, said Dr. Young, who is also a mentor for the Society of Hospital Medicine's Project BOOST.Before they arrive, SNF staff de-identifies a set of transfer paperwork from the Northwestern hospitalists. Then the hospitalists are asked to write orders based on the information they provided to the SNF. “Usually, this knocks people's socks off,” Dr. Young said. “They say, ‘How am I supposed to admit the patient? I don't know this, this, and this.’”The exercise was developed by Dr. Heather Zinzella Cox, the director of postacute care services at IPC The Hospitalist Company in Delaware. It's one of the ways that Northwestern is working to improve the transition between the hospital and postacute care settings such as SNFs.Readmissions, ACOs Drive ChangeThe interaction between hospitals and SNFs is an area ripe for improvement. Preventing patient bounce-back from SNFs and other postacute care settings is a real opportunity for hospitals to improve readmission rates overall and protect themselves from penalties from Medicare's Readmissions Reduction Program. Starting in October 2013, the maximum penalties in the program jumped from 1% of base operating payments to 2%.The good news is that SNFs are willing partners when it comes to reducing readmissions, said Dr. Amy Boutwell, president of Collaborative Healthcare Strategies based in Lexington, Mass. Not only do SNFs count on hospitals as a referral source, but Medicare officials have signaled that it won't be long before SNFs will be subject to readmission penalties themselves, she said.But readmission penalties are only a small driver in terms of what is motivating hospital administrators to look at the hospital-SNF relationship with interest. The bigger push is coming from accountable care organizations, Dr. Boutwell said.Start TalkingDr. Boutwell advises hospitalists who aren't already actively engaged with their SNFs to start now. It's not something that needs signoff from the CEO. “This is collaboration between providers over the care of shared patients,” she said.And it's a leadership opportunity for hospitalists who are willing to step up and become champions for reducing readmissions in this area, she said. “If there's one thing to start on it's the hand-off to SNFs because they are motivated. They understand the landscape is changing.”Christiana Hospital in Newark, Del., has seen a significant decrease in its readmissions from SNFs for certain conditions after making some relatively minor changes, said Dr. Thomas Mathew, a hospitalist with IPC who works at the hospital and is a medical director at two area SNFs.He started by bringing a small group of hospitalists, nurses, and patient care facilitators over to a nearby SNF and talking about how the facility works and what information the SNF providers needed. The result was that they streamlined the discharge information that they sent over to the SNF and instituted standard provider-to-provider phone calls before patients were discharged from the hospital.Instead of a stack of information from the patient's stay, the hospitalists now identify some key information about the patient: an up-to-date medication history, a discharge summary, and a disease-specific clinical summary.Understanding SNFsPart of the reason that Dr. Young and others suggest that hospitalists visit SNFs when possible is to learn the capabilities of the facility as well as what unique workflow or regulatory issues could be preventing the providers there from following through on some of the hospitalists’ discharge instructions.Often, patients end up being readmitted to the hospital because they have higher acuity needs than the SNF can handle, said Dr. Zinzella Cox. And some facilities are better at managing patients with dementia, for example, either because they specialize in that type of care or they have a different staffing model. Hospitals “really do need to become knowledgeable about their nursing home facility partners,” said Dr. Zinzella Cox, who serves as medical director at several postacute care facilities in Delaware.Another common issue arises when transferring patients who need narcotics. The Drug Enforcement Administration doesn't allow physicians to voice order Schedule II drugs over the phone, and since many patients arrive at SNFs in the evening when a physician isn't onsite, they can't immediately get the narcotics they need. Some hospital physicians get around this issue by premedicating patients before they leave the hospital and then sending them to the SNF with a prescription already written.This is a good start, Dr. Zinzella Cox said, but doctors need to be sure that the prescription is written for a specific quantity administered at specific time intervals. Prescriptions that include ranges for administration don't comply with SNF regulations, she noted. If the prescription isn't valid, the physician at the SNF will have to write another, which can lead to delays.It all gets back to talking with the SNF providers, she said. “We really do need to communicate issues between the two care settings so we can work collaboratively together,” Dr. Zinzella Cox said.Tips for better transitionsDr. Robert Young offered some pointers to hospital physicians on how to improve patients transfers to SNFs: •Know the environment to which you're sending patients. There is a large variation in capability, ownership, specialty units, and staffing among SNFs. Ask if they have access to your hospital's electronic health record.•Be thoughtful about the discharge paperwork you send. Ask the SNF physicians what information they need.•Do a postdischarge follow-up phone call. Does the facility need more information? Were the discharge orders implemented?•Educate patients and families. Patients need to understand that an SNF is not a hospital and they likely won't be seen by a physician every day.•Use your tools. Work with a state Quality Improvement Organization to get data on the readmission rates for postacute care facilities in your area. When hospitalists at Northwestern University in Chicago began working on reducing hospital readmissions from postacute-care facilities, they soon realized that they didn't know that much about what actually goes on inside a skilled nursing facility (SNF). So they began a “field trip” program in which interested hospitalists could visit some SNFs where they commonly refer patients. It was a chance for the hospitalists to see firsthand the wide variation in nursing home staffing, the capabilities in terms of testing and treatment, and which facilities had specialty units for conditions such as heart failure or hip fracture. “You have to engage the [SNFs],” said Dr. Robert Young, a hospitalist at Northwestern who conducts research on postacute-care transitions. “You have to figure out what the [SNF] looks like.” The field trips are important, Dr. Young said, because physicians only get limited exposure to postacute care settings during residency training. Physicians may have a “geriatrics week” in residency, during which they spend a small amount of a time at an SNF and take care of a few of the patients there, but it doesn't provide a chance for a deep understanding of the setting, said Dr. Young, who chairs a Society of Hospital Medicine work group on reducing readmissions of SNF patients to hospitals. Northwestern is also pilot-testing an exercise in which their hospitalists can see how their transfer instructions are translated into care. The experience has been eye opening so far, said Dr. Young, who is also a mentor for the Society of Hospital Medicine's Project BOOST. Before they arrive, SNF staff de-identifies a set of transfer paperwork from the Northwestern hospitalists. Then the hospitalists are asked to write orders based on the information they provided to the SNF. “Usually, this knocks people's socks off,” Dr. Young said. “They say, ‘How am I supposed to admit the patient? I don't know this, this, and this.’” The exercise was developed by Dr. Heather Zinzella Cox, the director of postacute care services at IPC The Hospitalist Company in Delaware. It's one of the ways that Northwestern is working to improve the transition between the hospital and postacute care settings such as SNFs. Readmissions, ACOs Drive ChangeThe interaction between hospitals and SNFs is an area ripe for improvement. Preventing patient bounce-back from SNFs and other postacute care settings is a real opportunity for hospitals to improve readmission rates overall and protect themselves from penalties from Medicare's Readmissions Reduction Program. Starting in October 2013, the maximum penalties in the program jumped from 1% of base operating payments to 2%.The good news is that SNFs are willing partners when it comes to reducing readmissions, said Dr. Amy Boutwell, president of Collaborative Healthcare Strategies based in Lexington, Mass. Not only do SNFs count on hospitals as a referral source, but Medicare officials have signaled that it won't be long before SNFs will be subject to readmission penalties themselves, she said.But readmission penalties are only a small driver in terms of what is motivating hospital administrators to look at the hospital-SNF relationship with interest. The bigger push is coming from accountable care organizations, Dr. Boutwell said. The interaction between hospitals and SNFs is an area ripe for improvement. Preventing patient bounce-back from SNFs and other postacute care settings is a real opportunity for hospitals to improve readmission rates overall and protect themselves from penalties from Medicare's Readmissions Reduction Program. Starting in October 2013, the maximum penalties in the program jumped from 1% of base operating payments to 2%. The good news is that SNFs are willing partners when it comes to reducing readmissions, said Dr. Amy Boutwell, president of Collaborative Healthcare Strategies based in Lexington, Mass. Not only do SNFs count on hospitals as a referral source, but Medicare officials have signaled that it won't be long before SNFs will be subject to readmission penalties themselves, she said. But readmission penalties are only a small driver in terms of what is motivating hospital administrators to look at the hospital-SNF relationship with interest. The bigger push is coming from accountable care organizations, Dr. Boutwell said. Start TalkingDr. Boutwell advises hospitalists who aren't already actively engaged with their SNFs to start now. It's not something that needs signoff from the CEO. “This is collaboration between providers over the care of shared patients,” she said.And it's a leadership opportunity for hospitalists who are willing to step up and become champions for reducing readmissions in this area, she said. “If there's one thing to start on it's the hand-off to SNFs because they are motivated. They understand the landscape is changing.”Christiana Hospital in Newark, Del., has seen a significant decrease in its readmissions from SNFs for certain conditions after making some relatively minor changes, said Dr. Thomas Mathew, a hospitalist with IPC who works at the hospital and is a medical director at two area SNFs.He started by bringing a small group of hospitalists, nurses, and patient care facilitators over to a nearby SNF and talking about how the facility works and what information the SNF providers needed. The result was that they streamlined the discharge information that they sent over to the SNF and instituted standard provider-to-provider phone calls before patients were discharged from the hospital.Instead of a stack of information from the patient's stay, the hospitalists now identify some key information about the patient: an up-to-date medication history, a discharge summary, and a disease-specific clinical summary. Dr. Boutwell advises hospitalists who aren't already actively engaged with their SNFs to start now. It's not something that needs signoff from the CEO. “This is collaboration between providers over the care of shared patients,” she said. And it's a leadership opportunity for hospitalists who are willing to step up and become champions for reducing readmissions in this area, she said. “If there's one thing to start on it's the hand-off to SNFs because they are motivated. They understand the landscape is changing.” Christiana Hospital in Newark, Del., has seen a significant decrease in its readmissions from SNFs for certain conditions after making some relatively minor changes, said Dr. Thomas Mathew, a hospitalist with IPC who works at the hospital and is a medical director at two area SNFs. He started by bringing a small group of hospitalists, nurses, and patient care facilitators over to a nearby SNF and talking about how the facility works and what information the SNF providers needed. The result was that they streamlined the discharge information that they sent over to the SNF and instituted standard provider-to-provider phone calls before patients were discharged from the hospital. Instead of a stack of information from the patient's stay, the hospitalists now identify some key information about the patient: an up-to-date medication history, a discharge summary, and a disease-specific clinical summary. Understanding SNFsPart of the reason that Dr. Young and others suggest that hospitalists visit SNFs when possible is to learn the capabilities of the facility as well as what unique workflow or regulatory issues could be preventing the providers there from following through on some of the hospitalists’ discharge instructions.Often, patients end up being readmitted to the hospital because they have higher acuity needs than the SNF can handle, said Dr. Zinzella Cox. And some facilities are better at managing patients with dementia, for example, either because they specialize in that type of care or they have a different staffing model. Hospitals “really do need to become knowledgeable about their nursing home facility partners,” said Dr. Zinzella Cox, who serves as medical director at several postacute care facilities in Delaware.Another common issue arises when transferring patients who need narcotics. The Drug Enforcement Administration doesn't allow physicians to voice order Schedule II drugs over the phone, and since many patients arrive at SNFs in the evening when a physician isn't onsite, they can't immediately get the narcotics they need. Some hospital physicians get around this issue by premedicating patients before they leave the hospital and then sending them to the SNF with a prescription already written.This is a good start, Dr. Zinzella Cox said, but doctors need to be sure that the prescription is written for a specific quantity administered at specific time intervals. Prescriptions that include ranges for administration don't comply with SNF regulations, she noted. If the prescription isn't valid, the physician at the SNF will have to write another, which can lead to delays.It all gets back to talking with the SNF providers, she said. “We really do need to communicate issues between the two care settings so we can work collaboratively together,” Dr. Zinzella Cox said.Tips for better transitionsDr. Robert Young offered some pointers to hospital physicians on how to improve patients transfers to SNFs: •Know the environment to which you're sending patients. There is a large variation in capability, ownership, specialty units, and staffing among SNFs. Ask if they have access to your hospital's electronic health record.•Be thoughtful about the discharge paperwork you send. Ask the SNF physicians what information they need.•Do a postdischarge follow-up phone call. Does the facility need more information? Were the discharge orders implemented?•Educate patients and families. Patients need to understand that an SNF is not a hospital and they likely won't be seen by a physician every day.•Use your tools. Work with a state Quality Improvement Organization to get data on the readmission rates for postacute care facilities in your area. Part of the reason that Dr. Young and others suggest that hospitalists visit SNFs when possible is to learn the capabilities of the facility as well as what unique workflow or regulatory issues could be preventing the providers there from following through on some of the hospitalists’ discharge instructions. Often, patients end up being readmitted to the hospital because they have higher acuity needs than the SNF can handle, said Dr. Zinzella Cox. And some facilities are better at managing patients with dementia, for example, either because they specialize in that type of care or they have a different staffing model. Hospitals “really do need to become knowledgeable about their nursing home facility partners,” said Dr. Zinzella Cox, who serves as medical director at several postacute care facilities in Delaware. Another common issue arises when transferring patients who need narcotics. The Drug Enforcement Administration doesn't allow physicians to voice order Schedule II drugs over the phone, and since many patients arrive at SNFs in the evening when a physician isn't onsite, they can't immediately get the narcotics they need. Some hospital physicians get around this issue by premedicating patients before they leave the hospital and then sending them to the SNF with a prescription already written. This is a good start, Dr. Zinzella Cox said, but doctors need to be sure that the prescription is written for a specific quantity administered at specific time intervals. Prescriptions that include ranges for administration don't comply with SNF regulations, she noted. If the prescription isn't valid, the physician at the SNF will have to write another, which can lead to delays. It all gets back to talking with the SNF providers, she said. “We really do need to communicate issues between the two care settings so we can work collaboratively together,” Dr. Zinzella Cox said. Tips for better transitionsDr. Robert Young offered some pointers to hospital physicians on how to improve patients transfers to SNFs: •Know the environment to which you're sending patients. There is a large variation in capability, ownership, specialty units, and staffing among SNFs. Ask if they have access to your hospital's electronic health record.•Be thoughtful about the discharge paperwork you send. Ask the SNF physicians what information they need.•Do a postdischarge follow-up phone call. Does the facility need more information? Were the discharge orders implemented?•Educate patients and families. Patients need to understand that an SNF is not a hospital and they likely won't be seen by a physician every day.•Use your tools. Work with a state Quality Improvement Organization to get data on the readmission rates for postacute care facilities in your area. Dr. Robert Young offered some pointers to hospital physicians on how to improve patients transfers to SNFs: •Know the environment to which you're sending patients. There is a large variation in capability, ownership, specialty units, and staffing among SNFs. Ask if they have access to your hospital's electronic health record.•Be thoughtful about the discharge paperwork you send. Ask the SNF physicians what information they need.•Do a postdischarge follow-up phone call. Does the facility need more information? Were the discharge orders implemented?•Educate patients and families. Patients need to understand that an SNF is not a hospital and they likely won't be seen by a physician every day.•Use your tools. Work with a state Quality Improvement Organization to get data on the readmission rates for postacute care facilities in your area. Dr. Robert Young offered some pointers to hospital physicians on how to improve patients transfers to SNFs: •Know the environment to which you're sending patients. There is a large variation in capability, ownership, specialty units, and staffing among SNFs. Ask if they have access to your hospital's electronic health record.•Be thoughtful about the discharge paperwork you send. Ask the SNF physicians what information they need.•Do a postdischarge follow-up phone call. Does the facility need more information? Were the discharge orders implemented?•Educate patients and families. Patients need to understand that an SNF is not a hospital and they likely won't be seen by a physician every day.•Use your tools. Work with a state Quality Improvement Organization to get data on the readmission rates for postacute care facilities in your area.