April 13, 2018 The Misadventures of the Recently-Discharged Older Adult THE MISADVENTURES OF THE RECENTLY-DISCHARGED OLDER ADULT Robert E. Burke MD, MS April 13, 2018 I have no conflicts of interest to declare. LEARNING OBJECTIVES Describe use, costs, and outcomes of post-acute care Enumerate underlying causes for poor outcomes Identify opportunities for you to improve outcomes 1
CASE STUDY Mr BL, WWII Veteran Blind (macular degeneration) Hospitalized for lung resection-> delirious, fall risk Inpatient team planning dispo; his goal: return home WHERE SHOULD MR. L GO? 1) Discharge to home with caregiver 2) Home with home health care (HHC) 3) Skilled nursing facility/short-term rehab (SNF) 4) Inpatient rehab facility (IRF) 5) I prefer to keep all my patients in the hospital until they have fully recovered to baseline THE DIFFICULT QUESTIONS Mr. L: Why should I go to SNF? If I do go, what are my chances of returning home? His daughter: What are you going to do to maximize his chances? 2
PAC PREVALENCE, COST, & OUTCOMES DISCHARGES TO PAC INCREASING Burke et al, JAMA IM 2015; Jones et al., JAGS 2015 POST-ACUTE CARE COSTS RISING MedPAC Data Book, June 2017 3
OLDER ADULT INCREASE IN USA OUTCOMES OF SNF Hospital readmission Long-term care SNF Community living Death 4
OUTCOMES OF SNF AND HHC MedPAC Data Book, June 2017 READMISSIONS CORRELATED WITH DEATH AND COMMUNITY DISCHARGE RATES Outcome Living in community Different living situations, >2 versus 2 or less Mortality (30 days) Mortality (100 days) Adjusted OR (95% CI) 0.52 (0.44-0.62) 13.15 (4.86-35.58) 2.01 (1.60-2.54) 3.79 (3.13-4.59) Burke RE et al, JAMDA 2016 NH PLACEMENT IMPLICATIONS What is the average monthly cost of nursing home care in the United States? $3500 $5000 $7500 $10,000 5
NH PLACEMENT IMPLICATIONS What is the average monthly cost of nursing home care? $3500 $5000 $7500 $10,000 $7700/month*12 months= $92,400 If you started with 100 day SNF stay, add $13,400 US Administration on Aging, 2016 WHO PAYS? Medicare Medicaid Private insurance Long-term care insurance Out of pocket WHO PAYS? 6
ARE WE PREPARED FOR THESE COSTS? CAREGIVER SUPPORT? NH PLACEMENT WORSE THAN DEATH? Rubin et al JAMA IM 2016 7
WHY IT S THIS WAY, & HOW WE COULD FIX IT READMISSIONS PREVENTABLE? OIG: 22% of patients in SNF sustain adverse events 60% preventable Most result in hospital readmission MCBS: Largest risk factors for readmission modifiable Functional status, number of physician visits, IV meds, index hospital LOS, CHF RCT: Nearly 1/3 preventable on joint hospital-snf RCAs OIG, OEI-06-11-00370 Feb 2014 Burke et al, JAMDA 2016 Ouslander et al., JAMDA 2016 Horney et al., JAGS 2017 FIRST DRIVER Hospital factors: payment and personnel 8
QUICKER AND SICKER HOSPITAL DISCHARGES Burke et al, JAMA IM 2015 Burke et al, Med Care 2015 START OF HOSPITALISTS Kuo YF et al. N Engl J Med 2009;360:1102-1112 HOSPITALISTS ARE NOT SNF EXPERTS JAMDA 2014 Overall score: 5 of 10 Examples: Services not available at a SNF 22% correct Patient not appropriate for SNF transfer 45% correct Staffing at a SNF 67% correct 9
QUIZ When is the first physician visit required by Medicare for a newly admitted SNF patient? 1) Within 2 business days 2) Within 7 days 3) Within 14 days 4) Within 30 days QUIZ When is the first physician visit required by Medicare for a newly admitted SNF patient? 1) Within 2 business days 2) Within 7 days 3) Within 14 days 4) Within 30 days https://www.cms.gov/outreach-and-education/medicare-learning- Network-MLN/MLNMattersArticles/downloads/SE1308.pdf NURSE KNOWLEDGE OF SNF 2/3 of RNs work in hospitals or clinics Compared to 10% for SNF/HHC combined! Nearly 40% of LPNs work in SNF/HHC the predominant licensed workforce in NHs Geriatric experience/training for nurses highly variable HRSA National Center on Healthcare Workforce Analysis 2013 10
WHERE THE RUBBER HITS THE ROAD Sometimes getting someone to transfer into a SNF is the quickest way to get them out of the hospital, cause our goal is to get people out of the hospital as quickly as possible. -Nurse You know it used to be when you were in the hospital, they kept you until you were able to go home, but now they don t do that anymore, they send you to rehab. -Patient WHERE THE RUBBER HITS THE ROAD First he was going to go home with home care and then he was going to go to a SNF and then he had an aspiration event and had a real tight abdomen they were thinking imminent death was near.but then he started feeling and looking way better and so he could probably benefit maybe from some therapy. - Nurse WHAT CAN A NURSE DO? Advocate for what s best for the patient, not the hospital Align with hospital metrics if needed - LOS Bring your clinical expertise to discharge decisions Nudge the head of the team You know, I ve seen cases like this before and things can turn around quickly. What would you think about giving him one more day to see if he recovers enough to go home? Organize a visit to your friendly HHA/SNF 11
SECOND DRIVER Who should go to a SNF? REGIONAL VARIABILITY IS EXTREME Variation in Health Care Spending: Target Decision Making, Not Geography IOM 2013 UNCERTAINTY ABOUT PAC 12
PATIENT SELECTION RUSHED Sometimes I feel like I m annoying to family members I m just really putting pressure on them to make decisions quickly when they may not emotionally be in that space to make these decisions right away. -Social worker Burke et al., JAGS 2017 NO FEEDBACK FROM SNF I d be curious to see how they [the patients] are doing [in SNF]. I think it d be good to know whether we made the right call.or obviously if this patient went there and didn t do very well or passed away.it s be kind of good to know maybe some feedback. -Physical therapist NO CLEAR DECISION-MAKER In general, the patient kind of just goes with whatever the doctor has decided. -Nurse Physicians, at least here, are largely removed from that decision [for SNF]...usually the physical and occupational therapist determine what the patient needs. -Hospitalist Ultimately, it comes down to the doctor. -Physical therapist 13
PATIENTS AND CAREGIVERS ARE CONFUSED ABOUT SNF There were pages and pages of names, sort of confusing, and they were pushing me to pick a place, wanted me out of there right away, and all I could remember was I needed a place close to home So within two hours, a person from [SNF] came in, interviewed me and within another two hours, I was very nicely put in a van with a very nice driver and came to [SNF]. - Patient, community SNF WHAT CAN A NURSE DO? Sharp contrast in the roles of hospital nurses who are often silent partners and SNF nurses, who take a primary role in managing the fit for patients transitioning to SNF It s not really something nursing is deciding on. Don t really know what skilled nursing looks like in a SNF WHAT CAN A NURSE DO? Take an active role in decision-making Be the expert in the patient s home environment and supports, mobility, trajectory Find a way to get feedback How can decisions improve otherwise? 14
THIRD DRIVER Mismatch between SNF resources and patient needs USUAL CARE IN SNF <5% had HF self-education during SNF stay 14% had body weight documented daily 43% had a HF symptom documented daily 10% without prompting by EMR 80% had a blood pressure measurement daily Boxer RS, et al RN STAFFING IN SNF 70% of nursing homes reported RN care per resident: 30 minutes a day or less Long-Term Care Community Coalition, data.cms.gov 15
MODELS THAT WORK WHAT CAN A NURSE DO? Until there is more help, use predictive models to focus attention on high-risk patients* Come to the hospital or SNF with stories Mobilize resources Get geriatric training any way you can NICHE! (nicheprogram.org) AMDA (paltc.org) NADONA (nadona.org) HHNA/NAHC (hhna.org/nahc.org) *Burke RE et al., JAGS 2018 FOURTH DRIVER Poor transitional care practices 16
MISSING INFORMATION TO SNF Jones C et al., JAMDA 2017 MISSING INFORMATION TO HHC Medications, 43% Lines & Catheters, 53% Code Status, 53% Clinician Contact, 54% Contact Isolation, 58% Pending Studies, 59% Additional Tests Recommended, 61% 0% 10% 20% 30% 40% 50% 60% 70% Proportion of Respondents Identifying Domains as Insufficient WHAT CAN A NURSE DO? Transitional phone call Transfer, not a discharge How can the PAC providers get more information? What are they missing now? Ensure patients have what they need Paper scripts for scheduled meds Map the process where are the gaps?* Yvonne Chan RN - Sutter Mills Peninsula *Burke RE et al., JHM 2017 17
SEA CHANGE COMING Patient Protection and Affordable Care Act 2010 IMPACT Act 2014 Protecting Access to Medicare Act 2014 PAYMENT REFORMS More shared responsibility for outcomes/costs Bundled payments for care improvement (BPCI) Medicare Spending Per Beneficiary (part of hospital VBP) SNF Value-Based Purchasing (VBP) Readmission and community discharge rates in FY19 IMPLICATIONS Pressure on hospitals and SNFs/HHC to get it right Increasing interest in RNs and NPs in key roles Aligned incentives a rare opportunity The time is now 18
SUMMARY PAC costs rising, more older adults in PAC, outcomes poor Poor outcomes driven by: Hospital pressures and lack of staff with expertise in geriatrics/post-acute care Poor discharge decision-making processes Mismatch of patients needs and PAC resources Poor transitional care practices Enormous opportunities for nurses You are our best hope WHY NURSES? The Future of Nursing: Leading Change, Advancing Health National Academies/IOM, 2011 (https://www.nap.edu/read/1295) Key message #2: Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. THANK YOU Robert.Burke5@va.gov @BBurkeMD 19