We all know the sad story: Despite extensive rehab, a patient in a skilled nursing facility is failing. Instead of improving, she is finds herself returning to the local hospital with trouble breathing, heart failure, or unmanaged pain. Eventually, she may die in the hospital hooked up to a ventilator and feeding tube that she never wanted.

A team at Hebrew SeniorLife in Boston has tested a new model of care aimed at reducing those rehospitalizations. During a 2009-2010 demonstration, Hebrew SeniorLife’s  rehab facility reduced hospital visits by nearly 20 percent with a three-step process. It started by learning more about the kind of care patients and their families want, increasing the use of palliative care teams, and improving communication with hospitals. The final step is a regular interdisciplinary staff conference to review unplanned discharges to determine what went wrong and how to fix it.

This revolving door from hospital to nursing home and back is more common than we think.  In 2006, one-quarter of patients discharged from a hospital to a nursing facility ended up back in the hospital within 30 days, according to a recent article (behind a paid firewall) by Vince Mor and colleagues. These hospitalizations are often bad for patients and their families, and, Mor estimates, cost Medicare more than $4 billion-a-year.

The Hebrew SeniorLife program began at admission, where the rehab center collected information on what medications the patient used, what  advance directives she had, her health status and functional skills, and importantly whether she had been hospitalized three times or more in the past six months. If her answer to the last question was yes, a palliative care team met with the patient to discuss realistic treatment goals, and whether she could be best cared for in a hospital, nursing facility, or at home. Mostly, the team focused on learning what the patient wanted. Details on the progam appear in the June issue of the Journal of the American Geriatrics Society.

Finally, the facility organized a bi-weekly interdisciplinary meeting, called the Team Improvement for the Patient and Safety (TIPS) conference to review problems. Unlike many such conferences, this one is open to the entire nursing home staff from physicians to maintenance workers and also includes participation from the team that cared for the patient in the hospital and even outside experts.  The sessions are run by Dr. Randi Berkowitz, the rehab center’s medical director.   

Can other facilities copy this model? Maybe. It costs some additional money that is not reimbursed though Medicare. However, it may fit well with some provisions of the 2010 health law, including Accountable Care Organizations and bundled payments, where hospitals, nursing facilities, doctors, and other providers team to provide better integrated care  to chronically ill patients. In addition, the 2010 law’s strict limits on payments for hospital readmissions will create new incentives for hospitals and nursing homes to partner to prevent costly roundtrips.

This model may end up saving money but nobody really knows. It may also improve staff morale and increase collaboration at nursing facilities—no easy task. The real benefit, though, would be to keep very vulnerable patients out the hospital, reduce their odds of delirium and infections, and perhaps  give them a better quality of life.