An emergency medicine physician and researcher suggests that skilled nursing facility residents with "ambulatory care-sensitive conditions" may be treated appropriately in healthcare settings other than the emergency department.
"Going to the emergency department can actually be somewhat traumatic" for a nursing home patient, says Renee Hsia, MD, an emergency department physician at the University of California San Francisco Department of Emergency Medicine.
Yet nearly one in five patients taken to a hospital emergency department from a skilled nursing facility are treated for so-called "ambulatory care-sensitive conditions," suggesting that some of their medical issues might be more effectively managed by the SNF's healthcare team, or in another less intense setting.
Hsia and colleagues from the UCSF Department of Emergency Medicine, analyzed annual National Hospital Ambulatory Medical Care Survey data from 2001 to 2010 whose Research Letter published Monday in JAMA Internal Medicine.
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She describes what it's like for these sick, elderly patients. "They're waiting a long time, sometimes in the hallway with a lot of commotion, and it's definitely not a comfortable environment. And these are patients who are going to be sensitive to different environment, in terms of delirium."
If a visit to the ED can be avoided, she says, it should be.
Hsia emphasizes that her report does not say that all patients brought to a hospital emergency department for ambulatory care-sensitive conditions don't need to be. Clearly some of them require that transfer.
"But maybe if you had other resources, or in a nursing home environment if there were other incentives available to treat the patient in that setting, they may not need to come to the ED."
"What we're asking is, 'Is there a significant portion of these nursing home patients who come to the ED because of conditions that might be treated in a nursing home?'" After all, skilled nursing homes have healthcare workers on staff, "and nursing homes tend to have relationships with physicians as well; There should be someone to at least call who is readily available for that."
"We need to ask, where is the best place that we can provide the care they need, and how do we get the most appropriate resources to the right patient at the right time?" Hsia asks. "Is it the ED, or should we provide more resources or create the right incentives so these people can be treated appropriately in an alternative setting?"
One finding from the study is that the percentage of nursing home patients transported to a hospital emergency department rose in that 10-year period by 12.8%, from 1.9 million patients in 2001 to 2.1 million in 2010.
Of those, 19% were for ambulatory care sensitive conditions, defined by the Agency for Healthcare Research and Quality as pneumonia, urinary tract infections, and other conditions such as asthma, chronic obstructive pulmonary disease, hypertension, appendicitis, congestive hart failure, dehydration, angina, and complications of diabetes.
Hsia says that it's not surprising that the percentage of skilled nursing home patients transported to an ED for care has risen; nursing home patients are sicker than they were 10 years ago, and more resources are available for patients with lower level of illness severity to be cared for in less intense settings such as home or assisted living residences.
Also, with the aging of the population, the number of skilled nursing home beds has outpaced demand, and if patients are not eligible for Medicare SNF coverage, not all patients and their families can afford the expense.
The issue is becoming increasingly important as hospitals struggle to reduce readmissions from skilled nursing facilities, which in 2006 were estimated at 21% and in 2010, rose to 23% according to Momotazur Rhaman, an investigator in health services policy and practice at Brown University.
Additionally, the Medicare Payment Advisory Commission (MedPAC), has been urging the Centers for Medicare & Medicaid Services to impose financial penalties on skilled nursing facilities with higher rates of 30-day hospital readmissions in a manner similar to CMS' up to 3% financial penalty to hospitals with higher rates of readmissions.
In its March 2012 report, MedPAC commissioners wrote that they "recommend reducing payments to SNFs with relatively high rates of rehospitalizations. Avoidable rehospitalizations of SNF patients increase Medicare’s spending, expose beneficiaries to additional disruptive care transitions, and can result in hospital-acquired infections or other adverse health consequences.”
The report noted that "a rehospitalization policy for SNFs would create comparable policies for SNFs and hospitals, thereby encouraging providers in both settings to work together to better manage the transitions between them."
In a report released earlier this month in Health Services Research, Rahman and co-authors at Brown and Harvard University linked reduced 30-day hospital readmissions among nursing home patients cared for in facilities that have linkages with those hospitals.
"Hospitals that own an SNF send about 45% of their patients to a single SNF compared to 26% in case of hospitals without a SNF," Rahman and colleagues wrote.
The greater the concentration of discharges from a hospital to a single SNF, the lower the number of rehospitalizations, "particularly in the days following SNF transfer…[a] finding that applies both to hospitals that own a SNF and to those that do not."