Earlier this month, the federal department of Health & Human Services concluded that more than one of every five skilled nursing facility (SNF) patients suffered serious harm from events such as medication errors, falls, or infections in 2011. Half were sent to the hospital as a result of these events. Six percent died. And 60 percent of these adverse events were deemed “clearly or likely” preventable by medical experts.
The findings have important implications for a major trend in the care of the frail elderly: the growing partnerships between hospitals and skilled nursing facilities. Increasingly, under financial pressure from Medicare payment rules and through new relationships such as Accountable Care Organizations and bundled payments, hospitals are transferring patients to SNFs faster than ever.
In these new arrangements, Medicare pays the partnering institutions (including hospitals, physicians, home health agencies, and nursing facilities) a fixed amount to provide the full range of care—from surgery to rehab—for a specific acute episode such as a heart attack or a broken hip. If the participating institutions can provide the care at less cost than the Medicare payment, they can share those extra dollars. If the care is more expensive or if quality is below standards, they risk losing money.
Imagine, for example, a patient fractures her hip. She may go the hospital emergency department, be admitted to the hospital, have her hip repaired by an orthopedic surgeon, and then be sent to a SNF for rehab. In this model, the patient may be transferred from the hospital to the nursing facility within a day or perhaps even a few hours of the surgery.
But the model only works if the SNF can provide high quality care at a low cost. The trouble is that nursing home staffs are frequently not well trained to care for very sick patients that come directly from hospitals. In a 2012 article for Health Progress, the journal of the Catholic Health Assn, I described the challenges nursing facilities face in this new environment and described some best practices
The sorts of adverse events identified by the HHS study are not only very bad for patients, they also impose financial costs on the health systems participating in these cooperative, risk-based models.
And if poor nursing home care resulted in, say, an infection at the site of the hip surgery, the financial penalties would be even stiffer. Even in traditional fee-for-service, Medicare may pay a hospital nothing if that patient is readmitted.
While hospitals are looking to partner with nursing facilities, they are being increasingly careful about who they buddy up with. They won’t do business with facilities that have high rates of readmissions or adverse events such as those identified by HHS.
For all the risks faced by hospitalized patients, they may be safer in a hospital than in a SNF, according to CMS studies. While 22 percent of nursing homes patients suffer adverse events, only about 13 percent do so in hospitals.
HHS figures that in 2011 Medicare paid nearly $3 billion to provide hospital care for elders who suffered an adverse event in a nursing facility. But in the new payment systems, those costs will directly hit the hospitals and their partners.
These new financial models could help solve the problem of poor care in nursing facilities. Supporters hope that pressure from hospitals and health systems will accomplish what decades of regulation has not: Get nursing facilities to hire sufficient and better–trained staff that can prevent many of these tragic events.
An important note about the HHS study: It looked only at post-acute and rehab care in SNFs that are paid by Medicare. It did not attempt to measure these adverse events in Medicaid-funded long-stay nursing homes.
Do you agree with the OIG’s prescriptive reliance on future PI/QI initiatives (e.g., QAPI) to address reported issues and concerns? Continued delay of QAPI reg’s is inexcusable.
Although the ACA’s Hospital Readmissions Program is the stick compared to the value-based payment models’ carrot you describe above, I believe it is also an important element to incent acute and PA/LTC providers to partner and collaborate. I believe HR 4188 (the Establishing Beneficiary Equity in the Hospital Readmission Program Act) is misguided.
My thoughts on that can be found at http://policypub.com/2014/03/13/accountability-without-responsibility/
~ Scot
Scot: No regulation in my memory has done more to change the mindset of hospital administrators that the readmission penalty. Yet, regulatory penalties alone will not create the well-integrated care system patients need. We also need that payment carrot.
As someone working in field, the report published by Health & Human Services was of great interest to me. I will be the first to acknowledge that we should – and can – do a better job at skilled nursing facilities. At the same time, some of the conclusions generated by the report are misleading and based on unrealistic assumptions about the nature of care and the people receiving them.
In particular, the notion that injuries from falls are preventable is not entirely accurate. Falls will always happen, and nursing homes must balance the need for a resident’s independence with regard for their risk for falls. There are easy ways to eliminate all falls – simply use physical or chemical restraints on any resident with a fall risk. Yet – and I hope you are as horrified at this prospect as I am – doing so will have negative consequences on many other aspects of a resident’s well being – from pressure ulcers, to depression, to infection.
In the nursing homes in my organization that have adopted a more person-centered approach, we have found that fall rates have increased. Yet these residents report the highest satisfaction and have the best level of general health as measured by Medicare’s Quality Measures statistics. In fact, I’ve found a positive correlation across the US between a high rate of falls and 5-Star nursing homes.
Simply looking at the falls numbers and having a knee-jerk reaction that nursing homes are doing a poor supervisory job of those residents is not taking the whole picture into account. We must balance resident safety and resident well-being. A nursing home is not a guard against all malady – it is just a safer place to be than a resident would be on their own.
That HHS did not strongly endorse additional punitive measures against nursing homes after the report’s publication means that at least someone in that office is versed in these nuances.
Joshua:
You are absolutely right. Falls especially are a difficult issue. A person-centered environment gives people freedom of movement and, sometimes, that can mean a fall. We all balance risk and choice in our lives. SNF patients should be no different (assuming they have a cognitive ability to decide).
But I believe the main point of the HHS study is correct: There are too many examples of poor quality SNF care that lead to medication errors, infections, and, yes, falls.