Inappropriate Hospitalization of Nursing Facility Residents: A Symptom of a Sick System of Care for Frail Older People

Almost 12 years ago, in a study published in the Journal, Zimmer and his colleagues documented the potential of a Medicare “sudden decline” benefit to reduce acute hospitalization of nursing facility (NF) residents.1 They demonstrated that by reimbursing the NF and the physician for reasonable costs associated with the assessment and management of acutely ill NF residents, the trauma and risks of acute hospitalization could be avoided in a large proportion of cases at a savings to Medicare of about $3000 per episode. Now, more than a decade later, Saliba and her colleagues report in this issue of the Journal that nearly one of every two acute hospitalizations of NF residents may be inappropriate.2 These investigators used a careful and comprehensive process of structured implicit review to make their determinations of appropriateness. Their approach was conservative (i.e., it erred on the side of judging an admission appropriate), took into account advance directives, and resulted in a high degree of interrater agreement. Why is it that on the one hand, strategies exist to reduce the hospitalization of NF residents, and on the other, many NF residents are hospitalized inappropriately? The answer to this question is complex and multifaceted, but, we suggest, it has a lot to do with our fragmented system of care for the frail geriatric population and the reimbursement system that supports it. See also p 154 Nursing facility residents are frailer and more medically complex than a decade ago, and physically frail NF residents are the most likely to be hospitalized.3 Admission to an acute hospital can be a traumatic event for a NF resident and her or his family. Transfer to the hospital may be physically uncomfortable and disorienting, as can be the multiple tests and procedures commonly performed in the emergency room before admission. We are all familiar with the iatrogenic problems that can befall frail older patients in the acute hospital setting, including delirium, falls, incontinence, dehydration, adverse drug effects, and nosocomial infections. There is also the expense. The costs of acute hospitalization can run into thousands of dollars per day, whereas the costs of care in even the best NFs generally does not exceed $300 per day. As we discuss further below, however, the bearers of these costs and their incentives are quite different. Many factors contribute to the decision to transfer a NF resident to an acute hospital.4, 5 These include the availability of on-site medical assessment and follow up; the ability to obtain diagnostic tests (X-rays, blood work, urinalysis, etc.) and their results in a timely fashion; the number and capabilities of licensed nursing staff in the facility, especially related to intravenous therapy, respiratory monitoring, and treatment; the availability of geropsychiatry evaluation and management services; and the documentation and clarity of advance directives related to the residents'preferences regarding acute hospital care or other invasive procedures. However, similar to many of the decisions we make in the current U.S. healthcare system (and, for that matter, many of the decisions made in most segments of our society), economic incentives often play a powerful role in the decision to transfer a NF resident to an acute hospital. The most important party in this situation, the NF resident, has to bear the cost of any deductibles and co-payments associated with hospitalization or some of the additional costs of treating acute illness in the NF. In general, however, the resident and/or responsible family have little influence on the decision to hospitalize in the absence of specific advance directives. The decision is made most often by the primary care physician or a covering physician. In the fee-for-service system, the physician has a potential financial incentive to hospitalize because he or she will be paid daily to see a hospital inpatient, whereas Medicare will generally deny multiple visits in the NF even if they are medically necessary. One of the components of the “sudden decline” benefit tested by Zimmer and colleagues was, in fact, reimbursement for repeated physician visits to the NF to follow up acute illnesses.1 The acute hospital also stands to gain financially if it has beds available and the NF resident is admitted and discharged within the diagnosis-related groups (DRG)-based length of stay. On the other hand, the NF has a financial incentive to discharge residents who require subacute or acute services that are not directly reimbursed in the NF setting. This incentive has recently become even stronger for NF residents on Medicare Part A because of the introduction of the prospective payment system (PPS). Some managed care organizations have developed special long-term care programs in which there are financial disincentives, and in some case incentives, to avoid hospitalization of NF residents. These programs generally succeed in reducing emergency room visits and hospitalization by utilizing nurse practitioners and physician's assistants in an enhanced on-site primary care role.6-9 These economic incentives and the multiple factors influencing the decision to hospitalize NF residents highlight the importance of the study by Saliba and colleagues.2 Rating the appropriateness of any healthcare intervention is tricky at best and fraught with numerous pitfalls. The systematic and sensible approach toward this complex issue taken by these investigators should be applauded. Their work will certainly assist us in further studies of the appropriate care of NF residents who become subacutely or acutely ill. Although the methods described by Saliba et al. are certainly a step in the right direction, the appropriateness of the hospitalization of NF residents, as well as of noninstitutionalized frail older people, will not be optimized until our fragmented system of care for this population, and the often perverse financial incentives it fosters, are addressed. These problems are not unique to our non-system of geriatric health care in the U.S. Similar issues are faced by our colleagues in Canada10 and in many other countries that have universal health insurance. Innovative models of care, such as the Program of All-Inclusive Care for the Older (PACE) in the U.S.11, 12 and the System of Integrated Care for the Frail Older (SIPA) in Montreal10 have been developed and implemented. The overall success of these programs remains to be determined, and they face numerous challenges — not the least of which is adequate capitation.10, 12 Recent and ongoing cutbacks in the Medicare program resulting from the Balanced Budget Amendment are undermining efforts to reform the current system. Despite the overall projected budget surplus, concern continues to be focused on reimbursement levels rather than on innovative ways to provide appropriate and cost-effective care for the rapidly growing frail geriatric population. In the Saliba et al. study, poor quality of care was associated closely with inappropriate transfer to an emergency room and/or inappropriate hospitalization.2 Quality of care in NFs is an ongoing concern and often involves inadequate medical supervision, high staff turnover rates, limited educational opportunities, and marginal staff-to-resident ratios. In recent years, there has been an increasing number of successful plaintiff lawsuits against NFs alleging poor care and neglect. These lawsuits indicate a rising level of concern among the public regarding what is an acceptable level of NF care. Physicians and other members of the NF multidisciplinary care team must increase their dialogue with families of NF residents in order to determine rational treatment goals and realistic expectations. Increasing educational programs for NF staff and the use of risk management programs can also potentially improve the quality of care we deliver.13 In our view, it is incumbent upon the members of the American Geriatrics Society, in collaboration with its newly established Foundation for Health in Aging and other like-minded organizations, to work with the public and with public policy makers to develop better approaches than currently exist for our frail older patients and their caregivers. Examples of such approaches have been described recently in our journal14 and elsewhere.15 Inappropriate hospitalization of NF residents is a symptom of a much more costly and critical problem in our healthcare system. We must work together to develop more coordinated systems of care for frail older people. These systems must have properly aligned financial incentives and respect for the preferences and quality of life of this population. If we do not address the current situation urgently and diligently, the discipline of geriatrics will suffer and, more importantly, so will our patients and their caregivers.

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