JAMDA 15 (2014) 607.e1e607.e3
JAMDA journal homepage: www.jamda.com
Editorial
Clarion Call for a Dedicated Clinical and Research Approach to Post-Acute Care Do Gyun “Luke” Kim MD, Barbara J. Messinger-Rapport MD, PhD, FACP, CMD * Cleveland Clinic Lerner College of Medicine, Section of Geriatric Medicine, Cleveland, OH
The American Medical Directors Association, referred to as AMDAe Dedicated to Long-Term Care Medicine, changed its name in 2014 to AMDAeThe Society for Post-Acute and Long-Term Care Medicine. With the growing recognition that post-acute care medicine requires a dedicated clinical skill set and research effort into healthcare outcomes, it may be appropriate for JAMDA to reflect these differences as well. About 20% of hospitalized Medicare Beneficiaries were discharged to subacute units and skilled nursing facilities (referred to collectively as SNFs) for post-acute care (PAC) in 20111 because of either complicated nursing needs or functional decline during hospitalization.2 This percentage may have been driven by implementation of the hospital inpatient prospective payment system, reducing the length of hospital stay and exponentially increasing the use of postacute care facilities.3 Medicare SNF costs in 2000 were $12 billion, and by 2011 had risen to $31.3 billion.1,4,5 Despite the burgeoning number of older adults receiving PAC in SNFs, these settings have not received the attention to their healthcare outcomes that hospitals have received in the past decade or more. Patients discharged from the hospital to SNFs have a higher mortality rate than those discharged to home.6 For example, when discharged to SNFs with a diagnosis of heart failure, patients had a 53.5% 1-year mortality rate compared with 29.1% for patients discharged to home (P < .0001).7 Although a portion of the adverse outcome is driven by the advanced average age of patients and the burden of comorbidity, there is likely substantial opportunity to improve facility care. In 2014, the Office of Inspector General (OIG) reported that 33% of Medicare beneficiaries in SNFs experienced adverse events, and physician reviewers determined that 59% of these events were clearly or likely preventable.8 These findings are comparable to (and perhaps slightly worse than) hospital adverse event rates. In 2010, the OIG found that 27% of hospitalized Medicare beneficiaries experienced adverse and temporary harm events, with nearly one-half of the events being preventable.9 The OIG reported that about one-third of identified events in SNFs were medication related, often causing delirium. Infections including catheterassociated urinary tract infection, Clostridium difficile, aspiration pneumonia, and surgical wound infections constituted about a The authors declare no conflicts of interest. * Address correspondence to Barbara J. Messinger-Rapport, MD, PhD, FACP, CMD, Cleveland Clinic Lerner College of Medicine, Section of Geriatric Medicine, Desk X10 Cleveland Clinic, 10685 Carnegie Ave, Cleveland, OH 44195. E-mail address: [email protected] (B.J. Messinger-Rapport).
quarter of events. The remainder of identified issues involved falls, electrolyte disturbances resulting in acute kidney injury, pulmonary embolus, and other care incidents.8 Addressing the adverse events and poor outcomes of SNF postacute care requires attention to many factors, including regulatory issues, quality measures, practitioner staffing models, and best clinical practices. Regulatory PAC in a SNF is currently regulated as nursing home care. This care model requires, for example, the facility to conduct a comprehensive evaluation of the “resident,” including assessment for delirium, within 14 days. The attending physician must perform an initial comprehensive examination within 30 days of admission, then perform an established patient visit at least every 30 days afterwards for the first 90 days. States may allow some of these visits to be delegated to a nonphysician provider. A pharmacist must review the patient’s drugs within 30 days then at least monthly. These evaluations can certainly be performed earlier and more often if medically indicated. The optimal intervals for assessment have not been determined. However, patients often leave the hospital with delirium, polypharmacy, intravenous medications, and metabolic derangements, suggesting that closer follow-up is needed for the PAC patient recently discharged from the hospital than for the resident recently admitted from the community for long-term care. The last major change in legislation and regulation of nursing home care occurred in 1987 (the Nursing Home Reform Act). Legislation and regulation within the 2010 Affordable Care Act have glossed over PAC despite its major role in outcomes. The time for new nursing home legislative reform is overdue. Quality Measures The quality measures utilized in the nursing home, such as urinary incontinence and pressure ulcers, are certainly valid in PAC. Currently, there are some differences in quality measures between short-stay and long-stay patients. However, there are no dedicated PAC quality measures for aspects of patient care such as average length of stay (excluding readmissions), hospital readmission rates, rate of discharge to the community, rate of transition to long-term care, etc. Standardized functional outcome measures throughout the acute and post-acute care spectrum could drive additional quality measures to
1525-8610/$ - see front matter Ó 2014 AMDA e The Society for Post-Acute and Long-Term Care Medicine. http://dx.doi.org/10.1016/j.jamda.2014.05.005
607.e2
Editorial / JAMDA 15 (2014) 607.e1e607.e3
compare function at admission and discharge. Frequency of goals of care discussion and recognition of those whose care may be better served as palliative rather than skilled or curative could be measured as well. A Center for Medicaid and Medicare Services 5-star rating dedicated to PAC (rather than combining short- and long-stay patients together in a facility rating) could be a useful summary rating to both payers and patients. It would be an added value if quality assessment could account for the medical acuity within the facility. For example, a facility with a hemodialysis unit whose newly admitted patients have highly variable weight, blood pressures, and metabolic abnormalities during the first 1e2 weeks may require more (and expensive) medications, and much more nursing and practitioner (physician plus nonphysician provider) attention to attain a good outcome compared with a facility whose typical admissions are postsurgical orthopedic patients. Other patients with higher costs and higher nursing and physician needs are post-transplant patients, patients with infections requiring expensive intravenous or oral medications because of resistance patterns, and patients with cancer on oral antineoplastic medications. The current measure of acuity is the resource utilization groups, which drives reimbursement via therapy minutes. Lack of a practical measure of acuity limits the ability of facilities to be reimbursed at a higher rate for justified nursing and medical expenses, as well as limits the ability to compare facilities. Practitioner Staffing Models The optimal physician staffing model for PAC is not known. The limited research to date on staffing models has looked at nursing home care, in which post-acute care data and long-term care data were combined. The traditional nursing home practice model is the community physician with both an office and hospital-based practice. These physicians, compared with those who do not care for nursing home patients, are more likely to have a hospital practice (60% vs 39.5%), see more patients each week (105 vs 78), and work more hours each week (57 vs 49).10 Another study found that community physicians cared for 70% of residents, and 60% of facilities had no daily physician presence.11 There is a concern that this model is not designed to provide care for patients recently discharged from the hospital with substantial nursing and medical needs. An alternative model is the closed staff model. In this model, a very few number of physicians care for all the patients in the facility, resulting in greater physician visibility. These physicians may or may not receive a salary from the facility. Another model is the physiciannurse practitioner (or physician assistant) model, where the nonphysician provider has a consistent and visible presence in the facility. Selected outcomes (eg, response to emergencies, hospitalization rates, satisfaction) may be superior in midlevel provider and closed models compared with the traditional nursing home physician model.11e13 Physicians who specialize in nursing home care rather than seeing patients in multiple settings may be more visible at the nursing home, have lower hospitalization rates, and reduced use of medications.11,14 However, a comparative effectiveness trial of a designated PAC physician (assigned to most residents in the nursing home and with set hours in the facility each week) compared with a historical traditional nursing home physician practice model had disappointing results after 6 months.15 Laboratory test costs (borne by the PAC facility in a Medicare Part A covered stay) were 54% higher in the PAC physician model. Important outcomes such as falls, fallers, unplanned discharges, medication errors and pharmacy costs were not statistically different in the designated PAC physician model.15 It is possible that a model, which combines hospital discharge planning with a designated post-acute care, salaried physician may be more effective than a designated PAC physician model alone. The
Cleveland Clinic demonstrated a reduction in the 30-day hospital readmission rate with such as model.16 A different model developed by the University of Michigan employed its physicians and nurse practitioners in designated community PAC facilities. Each facility had a University of Michigan medical director who guided the facility regarding specialized testing and medications needed for patients with high medical needs, such as post-transplant patients. They demonstrated a reduction in length of stay without increase in readmission rate.17 Another challenge to care is Health Information Exchange. The Affordable Care Act incentivized hospitals and physicians to develop electronic health records (EHRs), but post-acute and long-term care facilities were inadvertently omitted. Nevertheless, EHR systems have proliferated in all settings, including hospitals, physician offices, and post-acute care facilities. Unfortunately, the EHR is usually different in each setting, impairing Health Information Exchange (HIE) and making it challenging for practitioners to attain familiarity with the PAC EHR. In addition, nursing facility EHRs are designed to maximize reimbursement by optimizing resource utilization group scores, rather than maximize use of best practices in important conditions such as diabetes and heart failure. There is also a lack of electronic, real-time HIE between hospitals, emergency department, post-acute and long-term care facilities, pharmacies, dialysis centers, hospice, and physician offices. Medication lists, functional status, advance directives, test results, and other important data usually are updated by hand when the patient visits each site of care, resulting in delayed and often erroneous information. Best Practices An example of a clinical problem in need of research and for which a best practice is needed is delirium. Approximately 23% of post-acute admissions have delirium.18 Mortality rate in the 6 months after PAC admission is 5.7% in those without delirium, 18.3% in those with subsyndromal delirium, and 25% in those with delirium.19 Those patients with delirium are more likely to have a longer length of stay, be rehospitalized, and be less likely to return to the community. In those whom the admission delirium resolves within 2 weeks, the ability to perform activities of daily living is more likely to return to the preadmission level. If delirium is prolonged, the likelihood of regaining premorbid perform activity of daily living level is low.20 The PAC facility must identify delirium early and address the underlying medical cause in order to reduce severity and duration, as well as reduce the incidence of delirium for those patients arriving without delirium. The Delirium Abatement Program was a multifacility, multicomponent comprehensive, intensive, and expensive program that demonstrated an improvement in the documentation of delirium but no difference in duration of delirium, mortality, or functional ability.21 Although there is ongoing delirium research in the hospital setting22e25 and some delirium research in the long-term care setting,26,27 there is a still minimal attention to delirium in PAC. A second example of a clinical problem in need of attention in PAC is heart failure, both acute and chronic, and specifically attention to heart failure with preserved ejection fraction (HFpEF). Nearly 25% of Medicare beneficiaries hospitalized with heart failure are discharged to a SNF.7,28 Their 30-day mortality rate is 14.4%, 30-day rehospitalization rate is 27%, and 1-year mortality rate is 54%.7 The majority of older adults with HF have HFpEF, rather than heart failure with reduced ejection fraction (HFrEF). There are no clinical care recommendations with an “A” (strong) level of evidence for HFpEF, compared with multiple for than HFrEF.29 The only class I recommendations for HFpEF are to control the blood pressure and to use diuretics for symptom control. These recommendations have levels of evidence “B” and “C,” respectively, since evidence to support the
Editorial / JAMDA 15 (2014) 607.e1e607.e3
recommendations is very limited. Also, the guideline does not specify the optimum BP medication or BP target.29 Also, it is not known how to manage HF in the SNF to minimize adverse outcomes. Several programs, including the randomized controlled trial “SNF-connect” are ongoing.30 Other clinical problems in need of best practices include PAC management of malnutrition, acute kidney injury, and polypharmacy. Summary Care transition research currently focuses on hospital to home. There needs to be more attention paid to the transition from hospital to SNF, and from SNF to home, and for the care in between. Legislative and regulatory changes as well as financial incentives may be needed to help facilities and practitioners realign care processes to optimize patient outcomes. JAMDA can help by encouraging submissions on regulatory issues; quality measures; practitioner staffing models; and, best clinical practices dedicated to post-acute care. References 1. Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. Chapter 8. Skilled Nursing Facility Services. March 2013. 2. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med 1993; 118:219e223. 3. Ackerly DC, Grabowski DC. Post-Acute Care ReformeBeyond the ACA. N Engl J Med 2014;370:689e691. 4. U.S. Department of Health and Human Services. Office of the Actuary, National Health Statistics Group. SNF Utilization Chart; 2010. 5. Medicare Payment Advisory Commission. Skilled Nursing Facility Services Payment System. October 2011. 6. Walter LC, Brand RJ, Counsell SR, et al. Development and validation of a prognostic index for 1-year mortality in older adults after hospitalization. JAMA 2001;285:2987e2994. 7. Allen LA, Hernandez AF, Peterson ED, et al. Discharge to a skilled nursing facility and subsequent clinical outcomes among older patients hospitalized for heart failure. Circ Heart Fail 2011;4:293e300. 8. Office of Inspector General. Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries. February 2014. OEI-06-11-00370. 9. Office of Inspector General. Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. November 2010. OEI-06-09-00090. 10. Gazewood JD, Mehr DR. Predictors of physician nursing home practice: Does what we do in residency training make a difference? Fam Med (Kansas City) 2000;32:551e555. 11. Karuza J, Katz PR. Physician staffing patterns correlates of nursing home care: An initial inquiry and consideration of policy implications. J Am Geriatr Soc 1994;42:787e793.
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12. Kane RL, Flood S, Keckhafer G, Rockwood T. How EverCare nurse practitioners spend their time. J Am Geriatr Soc 2001;49:1530e1534. 13. Ackermann RJ, Kemle KA. The effect of a physician assistant on the hospitalization of nursing home residents. J Am Geriatr Soc 1998;46:610e614. 14. Fama T, Fox PD. Efforts to improve primary care delivery to nursing home residents. J Am Geriatr Soc 1997;45:627e632. 15. Gloth FM III, Gloth MJ. A comparative effectiveness trial between a post-acute care hospitalist model and a community-based physician model of nursing home care. J Am Med Dir Assoc 2011;12:384e386. 16. Velez VJ, Martin C, Kim DG, et al. Transitions of care models: Connected Care program is associated with reduced 30-day readmission rates. J Hosp Med 2014;9:246. 17. Joshi DK, Bluhm RA, Malani PN, et al. The successful development of a subacute care service associated with a large academic health system. J Am Med Dir Assoc 2012;13:564e567. 18. Marcantonio ER, Simon SE, Bergmann MA, et al. Delirium symptoms in postacute care. Prevalent, persistent, and associated with poor functional recovery. J Am Geriatr Soc 2003;51:4e9. 19. Marcantonio ER, Kiely DK, Simon SE, et al. Outcomes of older people admitted to post-acute facilities with delirium. J Am Geriatr Soc 2005;53:963e969. 20. Kiely DK, Jones RN, Bergmann MA, et al. Association between delirium resolution and functional recovery among newly admitted post-acute facility patients. J Gerontol A Bio Sci Med Sci 2006;61:204e208. 21. Marcantonio ER, Bergmann MA, Kiely DK, et al. Randomized trial of a delirium abatement program for post-acute skilled nursing facilities. J Am Geriatr Soc 2010;58:1019e1026. 22. Hakim SM, Othman AI, Naoum DO. Early treatment with risperidone for subsyndromal delirium after on-pump cardiac surgery in the elderly: A randomized trial. Anesthesiology 2012;116:987e997. 23. Devlin JW, Roberts RJ, Fong JJ, et al. Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, doubleblind, placebo-controlled pilot study. Crit Care Med 2010;38:419e427. 24. Han C, Kim Y. A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychosomatics 2004;45:297e301. 25. van Eijk MM, Roes KC, Honing ML, et al. Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: A multicentre, double-blind, placebo-controlled randomised trial. Lancet 2010;376:1829e1837. 26. Cole MG, McCusker J, Voyer P, et al. The course of subsyndromal delirium in older long-term care residents. Am J Geriatr Psychiatry 2013;21:289e296. 27. McCusker J, Cole MG, Voyer P, et al. Environmental factors predict the severity of delirium symptoms in long-term care residents with and without delirium. J Am Geriatr Soc 2013;61:502e511. 28. Dolansky MA, Xu F, Zullo M, et al. Postacute care services received by older adults following a cardiac event: A population-based analysis. J Cardiovasc Nurs 2010;25:342e349. 29. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: Executive summary: A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2013;62:1495e1539. 30. Boxer RS, Dolansky MA, Bodnar CA, et al. A randomized trial of heart failure disease management in skilled nursing facilities: Design and rationale. J Am Med Dir Assoc 2013;14:710.e5e710.e11.
JAMDA journal homepage: www.jamda.com
Editorial
Clarion Call for a Dedicated Clinical and Research Approach to Post-Acute Care Do Gyun “Luke” Kim MD, Barbara J. Messinger-Rapport MD, PhD, FACP, CMD * Cleveland Clinic Lerner College of Medicine, Section of Geriatric Medicine, Cleveland, OH
The American Medical Directors Association, referred to as AMDAe Dedicated to Long-Term Care Medicine, changed its name in 2014 to AMDAeThe Society for Post-Acute and Long-Term Care Medicine. With the growing recognition that post-acute care medicine requires a dedicated clinical skill set and research effort into healthcare outcomes, it may be appropriate for JAMDA to reflect these differences as well. About 20% of hospitalized Medicare Beneficiaries were discharged to subacute units and skilled nursing facilities (referred to collectively as SNFs) for post-acute care (PAC) in 20111 because of either complicated nursing needs or functional decline during hospitalization.2 This percentage may have been driven by implementation of the hospital inpatient prospective payment system, reducing the length of hospital stay and exponentially increasing the use of postacute care facilities.3 Medicare SNF costs in 2000 were $12 billion, and by 2011 had risen to $31.3 billion.1,4,5 Despite the burgeoning number of older adults receiving PAC in SNFs, these settings have not received the attention to their healthcare outcomes that hospitals have received in the past decade or more. Patients discharged from the hospital to SNFs have a higher mortality rate than those discharged to home.6 For example, when discharged to SNFs with a diagnosis of heart failure, patients had a 53.5% 1-year mortality rate compared with 29.1% for patients discharged to home (P < .0001).7 Although a portion of the adverse outcome is driven by the advanced average age of patients and the burden of comorbidity, there is likely substantial opportunity to improve facility care. In 2014, the Office of Inspector General (OIG) reported that 33% of Medicare beneficiaries in SNFs experienced adverse events, and physician reviewers determined that 59% of these events were clearly or likely preventable.8 These findings are comparable to (and perhaps slightly worse than) hospital adverse event rates. In 2010, the OIG found that 27% of hospitalized Medicare beneficiaries experienced adverse and temporary harm events, with nearly one-half of the events being preventable.9 The OIG reported that about one-third of identified events in SNFs were medication related, often causing delirium. Infections including catheterassociated urinary tract infection, Clostridium difficile, aspiration pneumonia, and surgical wound infections constituted about a The authors declare no conflicts of interest. * Address correspondence to Barbara J. Messinger-Rapport, MD, PhD, FACP, CMD, Cleveland Clinic Lerner College of Medicine, Section of Geriatric Medicine, Desk X10 Cleveland Clinic, 10685 Carnegie Ave, Cleveland, OH 44195. E-mail address: [email protected] (B.J. Messinger-Rapport).
quarter of events. The remainder of identified issues involved falls, electrolyte disturbances resulting in acute kidney injury, pulmonary embolus, and other care incidents.8 Addressing the adverse events and poor outcomes of SNF postacute care requires attention to many factors, including regulatory issues, quality measures, practitioner staffing models, and best clinical practices. Regulatory PAC in a SNF is currently regulated as nursing home care. This care model requires, for example, the facility to conduct a comprehensive evaluation of the “resident,” including assessment for delirium, within 14 days. The attending physician must perform an initial comprehensive examination within 30 days of admission, then perform an established patient visit at least every 30 days afterwards for the first 90 days. States may allow some of these visits to be delegated to a nonphysician provider. A pharmacist must review the patient’s drugs within 30 days then at least monthly. These evaluations can certainly be performed earlier and more often if medically indicated. The optimal intervals for assessment have not been determined. However, patients often leave the hospital with delirium, polypharmacy, intravenous medications, and metabolic derangements, suggesting that closer follow-up is needed for the PAC patient recently discharged from the hospital than for the resident recently admitted from the community for long-term care. The last major change in legislation and regulation of nursing home care occurred in 1987 (the Nursing Home Reform Act). Legislation and regulation within the 2010 Affordable Care Act have glossed over PAC despite its major role in outcomes. The time for new nursing home legislative reform is overdue. Quality Measures The quality measures utilized in the nursing home, such as urinary incontinence and pressure ulcers, are certainly valid in PAC. Currently, there are some differences in quality measures between short-stay and long-stay patients. However, there are no dedicated PAC quality measures for aspects of patient care such as average length of stay (excluding readmissions), hospital readmission rates, rate of discharge to the community, rate of transition to long-term care, etc. Standardized functional outcome measures throughout the acute and post-acute care spectrum could drive additional quality measures to
1525-8610/$ - see front matter Ó 2014 AMDA e The Society for Post-Acute and Long-Term Care Medicine. http://dx.doi.org/10.1016/j.jamda.2014.05.005
607.e2
Editorial / JAMDA 15 (2014) 607.e1e607.e3
compare function at admission and discharge. Frequency of goals of care discussion and recognition of those whose care may be better served as palliative rather than skilled or curative could be measured as well. A Center for Medicaid and Medicare Services 5-star rating dedicated to PAC (rather than combining short- and long-stay patients together in a facility rating) could be a useful summary rating to both payers and patients. It would be an added value if quality assessment could account for the medical acuity within the facility. For example, a facility with a hemodialysis unit whose newly admitted patients have highly variable weight, blood pressures, and metabolic abnormalities during the first 1e2 weeks may require more (and expensive) medications, and much more nursing and practitioner (physician plus nonphysician provider) attention to attain a good outcome compared with a facility whose typical admissions are postsurgical orthopedic patients. Other patients with higher costs and higher nursing and physician needs are post-transplant patients, patients with infections requiring expensive intravenous or oral medications because of resistance patterns, and patients with cancer on oral antineoplastic medications. The current measure of acuity is the resource utilization groups, which drives reimbursement via therapy minutes. Lack of a practical measure of acuity limits the ability of facilities to be reimbursed at a higher rate for justified nursing and medical expenses, as well as limits the ability to compare facilities. Practitioner Staffing Models The optimal physician staffing model for PAC is not known. The limited research to date on staffing models has looked at nursing home care, in which post-acute care data and long-term care data were combined. The traditional nursing home practice model is the community physician with both an office and hospital-based practice. These physicians, compared with those who do not care for nursing home patients, are more likely to have a hospital practice (60% vs 39.5%), see more patients each week (105 vs 78), and work more hours each week (57 vs 49).10 Another study found that community physicians cared for 70% of residents, and 60% of facilities had no daily physician presence.11 There is a concern that this model is not designed to provide care for patients recently discharged from the hospital with substantial nursing and medical needs. An alternative model is the closed staff model. In this model, a very few number of physicians care for all the patients in the facility, resulting in greater physician visibility. These physicians may or may not receive a salary from the facility. Another model is the physiciannurse practitioner (or physician assistant) model, where the nonphysician provider has a consistent and visible presence in the facility. Selected outcomes (eg, response to emergencies, hospitalization rates, satisfaction) may be superior in midlevel provider and closed models compared with the traditional nursing home physician model.11e13 Physicians who specialize in nursing home care rather than seeing patients in multiple settings may be more visible at the nursing home, have lower hospitalization rates, and reduced use of medications.11,14 However, a comparative effectiveness trial of a designated PAC physician (assigned to most residents in the nursing home and with set hours in the facility each week) compared with a historical traditional nursing home physician practice model had disappointing results after 6 months.15 Laboratory test costs (borne by the PAC facility in a Medicare Part A covered stay) were 54% higher in the PAC physician model. Important outcomes such as falls, fallers, unplanned discharges, medication errors and pharmacy costs were not statistically different in the designated PAC physician model.15 It is possible that a model, which combines hospital discharge planning with a designated post-acute care, salaried physician may be more effective than a designated PAC physician model alone. The
Cleveland Clinic demonstrated a reduction in the 30-day hospital readmission rate with such as model.16 A different model developed by the University of Michigan employed its physicians and nurse practitioners in designated community PAC facilities. Each facility had a University of Michigan medical director who guided the facility regarding specialized testing and medications needed for patients with high medical needs, such as post-transplant patients. They demonstrated a reduction in length of stay without increase in readmission rate.17 Another challenge to care is Health Information Exchange. The Affordable Care Act incentivized hospitals and physicians to develop electronic health records (EHRs), but post-acute and long-term care facilities were inadvertently omitted. Nevertheless, EHR systems have proliferated in all settings, including hospitals, physician offices, and post-acute care facilities. Unfortunately, the EHR is usually different in each setting, impairing Health Information Exchange (HIE) and making it challenging for practitioners to attain familiarity with the PAC EHR. In addition, nursing facility EHRs are designed to maximize reimbursement by optimizing resource utilization group scores, rather than maximize use of best practices in important conditions such as diabetes and heart failure. There is also a lack of electronic, real-time HIE between hospitals, emergency department, post-acute and long-term care facilities, pharmacies, dialysis centers, hospice, and physician offices. Medication lists, functional status, advance directives, test results, and other important data usually are updated by hand when the patient visits each site of care, resulting in delayed and often erroneous information. Best Practices An example of a clinical problem in need of research and for which a best practice is needed is delirium. Approximately 23% of post-acute admissions have delirium.18 Mortality rate in the 6 months after PAC admission is 5.7% in those without delirium, 18.3% in those with subsyndromal delirium, and 25% in those with delirium.19 Those patients with delirium are more likely to have a longer length of stay, be rehospitalized, and be less likely to return to the community. In those whom the admission delirium resolves within 2 weeks, the ability to perform activities of daily living is more likely to return to the preadmission level. If delirium is prolonged, the likelihood of regaining premorbid perform activity of daily living level is low.20 The PAC facility must identify delirium early and address the underlying medical cause in order to reduce severity and duration, as well as reduce the incidence of delirium for those patients arriving without delirium. The Delirium Abatement Program was a multifacility, multicomponent comprehensive, intensive, and expensive program that demonstrated an improvement in the documentation of delirium but no difference in duration of delirium, mortality, or functional ability.21 Although there is ongoing delirium research in the hospital setting22e25 and some delirium research in the long-term care setting,26,27 there is a still minimal attention to delirium in PAC. A second example of a clinical problem in need of attention in PAC is heart failure, both acute and chronic, and specifically attention to heart failure with preserved ejection fraction (HFpEF). Nearly 25% of Medicare beneficiaries hospitalized with heart failure are discharged to a SNF.7,28 Their 30-day mortality rate is 14.4%, 30-day rehospitalization rate is 27%, and 1-year mortality rate is 54%.7 The majority of older adults with HF have HFpEF, rather than heart failure with reduced ejection fraction (HFrEF). There are no clinical care recommendations with an “A” (strong) level of evidence for HFpEF, compared with multiple for than HFrEF.29 The only class I recommendations for HFpEF are to control the blood pressure and to use diuretics for symptom control. These recommendations have levels of evidence “B” and “C,” respectively, since evidence to support the
Editorial / JAMDA 15 (2014) 607.e1e607.e3
recommendations is very limited. Also, the guideline does not specify the optimum BP medication or BP target.29 Also, it is not known how to manage HF in the SNF to minimize adverse outcomes. Several programs, including the randomized controlled trial “SNF-connect” are ongoing.30 Other clinical problems in need of best practices include PAC management of malnutrition, acute kidney injury, and polypharmacy. Summary Care transition research currently focuses on hospital to home. There needs to be more attention paid to the transition from hospital to SNF, and from SNF to home, and for the care in between. Legislative and regulatory changes as well as financial incentives may be needed to help facilities and practitioners realign care processes to optimize patient outcomes. JAMDA can help by encouraging submissions on regulatory issues; quality measures; practitioner staffing models; and, best clinical practices dedicated to post-acute care. References 1. Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. Chapter 8. Skilled Nursing Facility Services. March 2013. 2. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med 1993; 118:219e223. 3. Ackerly DC, Grabowski DC. Post-Acute Care ReformeBeyond the ACA. N Engl J Med 2014;370:689e691. 4. U.S. Department of Health and Human Services. Office of the Actuary, National Health Statistics Group. SNF Utilization Chart; 2010. 5. Medicare Payment Advisory Commission. Skilled Nursing Facility Services Payment System. October 2011. 6. Walter LC, Brand RJ, Counsell SR, et al. Development and validation of a prognostic index for 1-year mortality in older adults after hospitalization. JAMA 2001;285:2987e2994. 7. Allen LA, Hernandez AF, Peterson ED, et al. Discharge to a skilled nursing facility and subsequent clinical outcomes among older patients hospitalized for heart failure. Circ Heart Fail 2011;4:293e300. 8. Office of Inspector General. Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries. February 2014. OEI-06-11-00370. 9. Office of Inspector General. Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. November 2010. OEI-06-09-00090. 10. Gazewood JD, Mehr DR. Predictors of physician nursing home practice: Does what we do in residency training make a difference? Fam Med (Kansas City) 2000;32:551e555. 11. Karuza J, Katz PR. Physician staffing patterns correlates of nursing home care: An initial inquiry and consideration of policy implications. J Am Geriatr Soc 1994;42:787e793.
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12. Kane RL, Flood S, Keckhafer G, Rockwood T. How EverCare nurse practitioners spend their time. J Am Geriatr Soc 2001;49:1530e1534. 13. Ackermann RJ, Kemle KA. The effect of a physician assistant on the hospitalization of nursing home residents. J Am Geriatr Soc 1998;46:610e614. 14. Fama T, Fox PD. Efforts to improve primary care delivery to nursing home residents. J Am Geriatr Soc 1997;45:627e632. 15. Gloth FM III, Gloth MJ. A comparative effectiveness trial between a post-acute care hospitalist model and a community-based physician model of nursing home care. J Am Med Dir Assoc 2011;12:384e386. 16. Velez VJ, Martin C, Kim DG, et al. Transitions of care models: Connected Care program is associated with reduced 30-day readmission rates. J Hosp Med 2014;9:246. 17. Joshi DK, Bluhm RA, Malani PN, et al. The successful development of a subacute care service associated with a large academic health system. J Am Med Dir Assoc 2012;13:564e567. 18. Marcantonio ER, Simon SE, Bergmann MA, et al. Delirium symptoms in postacute care. Prevalent, persistent, and associated with poor functional recovery. J Am Geriatr Soc 2003;51:4e9. 19. Marcantonio ER, Kiely DK, Simon SE, et al. Outcomes of older people admitted to post-acute facilities with delirium. J Am Geriatr Soc 2005;53:963e969. 20. Kiely DK, Jones RN, Bergmann MA, et al. Association between delirium resolution and functional recovery among newly admitted post-acute facility patients. J Gerontol A Bio Sci Med Sci 2006;61:204e208. 21. Marcantonio ER, Bergmann MA, Kiely DK, et al. Randomized trial of a delirium abatement program for post-acute skilled nursing facilities. J Am Geriatr Soc 2010;58:1019e1026. 22. Hakim SM, Othman AI, Naoum DO. Early treatment with risperidone for subsyndromal delirium after on-pump cardiac surgery in the elderly: A randomized trial. Anesthesiology 2012;116:987e997. 23. Devlin JW, Roberts RJ, Fong JJ, et al. Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, doubleblind, placebo-controlled pilot study. Crit Care Med 2010;38:419e427. 24. Han C, Kim Y. A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychosomatics 2004;45:297e301. 25. van Eijk MM, Roes KC, Honing ML, et al. Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: A multicentre, double-blind, placebo-controlled randomised trial. Lancet 2010;376:1829e1837. 26. Cole MG, McCusker J, Voyer P, et al. The course of subsyndromal delirium in older long-term care residents. Am J Geriatr Psychiatry 2013;21:289e296. 27. McCusker J, Cole MG, Voyer P, et al. Environmental factors predict the severity of delirium symptoms in long-term care residents with and without delirium. J Am Geriatr Soc 2013;61:502e511. 28. Dolansky MA, Xu F, Zullo M, et al. Postacute care services received by older adults following a cardiac event: A population-based analysis. J Cardiovasc Nurs 2010;25:342e349. 29. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: Executive summary: A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2013;62:1495e1539. 30. Boxer RS, Dolansky MA, Bodnar CA, et al. A randomized trial of heart failure disease management in skilled nursing facilities: Design and rationale. J Am Med Dir Assoc 2013;14:710.e5e710.e11.
