Reducing potentially preventable readmissions of nursing center residents is an important quality improvement goal and a top priority for nursing centers across the nation. Florida has some work to do, as our state ranks one of the highest in the nation. Florida Health Care Association’s Quality Cabinet has selected this issue to focus on as one of its 2018 initiatives.
Approximately 25 percent of persons admitted to a skilled nursing center are re-admitted to the hospital within 30 days. Hospital transfers can lead to substantial morbidity such as pressure ulcers, urinary tract infections because of catheters, other nosocomial infections, delirium, weight loss, severe muscle loss and polypharmacy. Hospitalizations also increase distress for the resident and their family. Of the hospitalizations from nursing centers, nearly half have been considered potentially avoidable. Preventing these events whenever possible is always beneficial to residents and has been identified by policymakers and providers as an opportunity to reduce overall health care system costs through improvements in quality. The issue has become a top priority for the Centers for Medicare and Medicaid Services (CMS) and managed care programs.
Researchers have studied, reviewed and analyzed rehospitalizations to determine the root cause analysis and to recommend promising practices to prevent or reduce preventable readmissions. The research revealed that more than one quarter of the hospital transfers that were evaluated could have potentially been preventable if there had been an earlier discussion of patient/family preferences and/or the presence of advance care plans and advance directives.
The CMS Requirements of Participation require that nursing centers engage in advance care planning with the resident and family. Advance care planning is supported by over 100 national organizations, such as AARP, the American Hospital Association, the American Medical Association and the Society for Post-acute and Long-term Care. The process of advance care planning is ongoing and affords the resident, family and others on the resident’s interdisciplinary health care team an opportunity to reassess the resident’s goals and wishes as the resident’s medical condition changes. It involves acknowledging all the options for medical care and deciding what fits one’s values, choices and preferences.
Advanced care planning is an integral aspect of the facility’s comprehensive care planning process and assures re-evaluation of the resident’s desires on a routine basis and when there is a significant change in the resident’s condition. The process can educate and empower the resident, family and the interdisciplinary team to be prepared for the time when a resident becomes unable to make decisions or is actively dying. To be successful, the facility should, upon admission, determine if the resident has an advance directive and, if not, whether he/she wishes to formulate one. As part of the comprehensive care planning process, the team should identify, clarify and review the existing care instructions and whether the resident wishes to change or continue these instructions. In addition to that, the facility should identify situations where health care decision-making is needed, such as a significant decline or improvement in the resident’s condition and once again, determining if resident wishes to change or continue these instructions.
The facility should also provide education and resources regarding advance care planning, palliative care and hospice, as appropriate.
Reducing potentially preventable readmissions of nursing center residents is an important quality improvement goal for nursing centers. Implementing a good advance care planning system can make a significant impact towards reaching your goals.
Advance Care Planning Resources
Honoring Choices Florida
The Conversation Project
Put It in Writing
American Bar Association