More Nurses in Nursing Homes Would Mean Fewer Patients Headed to Hospitals

Nursing home residents are frequently hospitalized.  Residents who have recently been admitted from the hospital are frequently rehospitalized.[1]  Many of these hospitalizations, which “can cause discomfort for residents, anxiety for their loved ones, morbidity due to iatrogenic events, and excess healthcare costs,”[2] are considered avoidable.  The 2010 National Healthcare Quality Report found that residents’ hospitalization rates for potentially avoidable conditions increased between 2000 and 2007.[3]

The costs of avoidable hospitalizations are enormous.  In March 2010, the Medicare Payment Advisory Commission (MedPAC) reported that in 2005, “potentially avoidable readmissions cost the [Medicare] program more than $12 billion” and that “In 2007, more than 18 percent of SNF stays resulted in a potentially avoidable readmission to a hospital.”[4]  Residents’ use of hospitals is expensive for the Medicare program, may create additional health care problems for patients, and is often seen as reflecting poor quality of care, both in the hospital (which may discharge patients too soon, often without adequate discharge planning) and in the nursing facility (which may have been unable to provide needed care).   Reducing hospitalizations and rehospitalizations could save Medicare dollars while improving quality of care for beneficiaries.

The Patient Protection and Affordable Care Act (ACA), the health care reform law enacted in 2010, addresses these issues through a variety of payment mechanisms.  Section 3025, the Hospital Readmissions Reduction Program, reduces a hospital’s reimbursement if a patient is rehospitalized within a time period specified by the Secretary, such as 30 days of discharge.  Unfortunately, advocates, including the Center for Medicare Advocacy, are concerned that section 3025 may result in increased use of observation status, a status that identifies hospitalized patients as “outpatients.”[5]  In addition to the changes in Section 3025, Section 3023 of the ACA authorizes a pilot program that provides a single payment for an episode of both acute and post-acute care.

While payment mechanisms may help reduce inappropriate unplanned hospitalizations, they do not address the reasons why nursing homes hospitalize their residents.  Understanding the reasons behind inappropriate hospitalizations of nursing home residents should help policymakers as they work to implement the ACA and to reduce hospitalizations.

The Kaiser Papers on Hospitalization

A primary cause of hospitalizations from nursing homes, discussed in the literature for more than 20 years, is the inadequate nurse staffing levels in nursing facilities.  Last fall, the Kaiser Family Foundation released two studies about the hospitalization of nursing home residents.  Their findings about why nursing home residents are hospitalized confirm earlier research in this field and point to the need to increase nurse staffing in nursing facilities as a way to improve quality of care in nursing facilities and reduce hospitalization and rehospitalization of residents.

The Kaiser study, “Financial Incentives in the Long-Term Care Context: A First Look at Relevant Information” identified the financial incentives that encourage hospitalization of nursing home residents.[6]  These incentives include Medicare payment policies for physicians, skilled nursing facilities, and hospice services as well as the dual roles of medical director and attending physician frequently being held by the same individual.

A companion study, based on interviews with physicians, nurses, social workers, and family members of residents, identified 10 factors that encourage hospitalization of nursing home residents: the limited capacity of nursing facilities to address medical issues; physicians’ preference for inpatient settings; concerns with liability for not hospitalizing; financial incentives for physicians and facilities; inability of assisted living facilities to address residents’ medical needs; lack of relationship between facility staff, physician, and family; lack of advance care planning; family preference; and behavioral health issues.[7]

Inadequate and Insufficient Staffing is a Key Factor Leading to Hospitalization of Nursing Home Residents

Although multiple factors influence a decision to hospitalize a nursing home resident, a key factor identified in the Kaiser reports and other studies discussed below is the lack of sufficient professional and paraprofessional nursing staff in nursing facilities.  The inadequate staffing in nursing homes has been recognized for a long time.

In 2001, the Centers for Medicare & Medicaid Services (CMS) issued a comprehensive report about nurse staffing in nursing facilities.  The report found that more than 97% of facilities do not have sufficient nursing staff to meet one or more federal staffing requirements and to prevent avoidable harm to residents and that 91% do not have sufficient nursing staff to meet five key care process areas (dressing/grooming; exercise; feeding assistance; changing wet clothes and repositioning; toileting).[8]  The report found insufficient numbers of professional nurses as well as insufficient numbers of aides.  Although resident acuity has increased in the decade since the CMS report was issued, staffing has not significantly changed, in terms of either absolute numbers of nursing staff or the professional qualifications of staff.

Largely as a result of inadequate staffing, residents experience poor care that leads to bad outcomes that could have been avoided if better care had been provided.  Nearly 20 years ago, the Senate Labor and Human Resources’ subcommittee on aging issued a staff report that identified the high cost of poor care and quantified the costs, citing research literature.  The report quantified $3.26 billion to pay for incontinence care; $1.2-12 billion to treat preventable pressure ulcers; $746.5 million for hip fractures for 18,500 residents ($40,000 per person); and nearly $1 billion for hospitalizations.[9]

The last finding was based on a 1989 study about social-cultural (i.e., non-clinical) factors that contribute to the hospitalization of nursing home residents.  Multiple factors were identified (generally, the same ones identified by Kaiser in its 2010 reports), such as lack of x-ray and pharmacy services at nursing homes, physician preference, and family pressure. The three-year study in three nursing facilities found that nearly half of the hospitalizations (48.2%) occurred because of social-structural reasons, rather than clinical reasons, and that 70% of the residents who were hospitalized “could have been treated in the nursing home if the nursing staff had been able to administer IV therapy.”[10]  Nursing facilities’ “insufficient and inadequately trained nursing staff” could not meet residents’ more complex health care needs.

Studies of hospitalization of nursing home residents suggest that hospitalization could be reduced if facilities employed geriatric nurse practitioners[11] or physicians, nurse practitioners, and physician assistants.[12]  The nursing home corporation Genesis HealthCare reports that it has employed more RNs, nurse practitioners, and physicians in its nursing facilities, resulting in an 11% decline in unplanned hospitalizations since 2004.  Sixty percent of Genesis facilities have a “‘transitional care unit,’ in which an RN-intensive staff team cares for residents who have been in the hospital within the past 25 days.”[13]  The RNs “are intravenous (IV)-certified.”  The transitional care units also have a nurse practitioner or physician on staff every day.

Conclusion

The multiple reasons for the hospitalization and rehospitalization of nursing home residents make the issue of avoidable hospitalizations complex and difficult.  But the hospitalization issue will not be resolved unless and until improved staffing in nursing homes is considered part of the solution.  The problem could be made worse if the solution focuses solely on financial incentives.  As Dr. James Ouslander and his colleagues wrote in their 2010 report, “[P]roviding financial incentives for reducing hospitalization without the necessary infrastructure could worsen care quality if NHs [nursing homes] are rewarded for managing sicker residents in the NH with inadequate capabilities to do so safely.”[14]

For more information, contact attorney Toby Edelman (tedelman@medicareadvocacy.org) in the Center for Medicare Advocacy’s Washington, DC office at (202) 293-5760.


[1] Concern about rehospitalization is, of course, broader than concern about nursing home residents.  But the concern about hospital readmissions is particularly significant for residents because nursing homes are the most frequent setting for post-acute care.
[2] Joseph G. Ouslander, Gerri Lamb, Mary Perloe, JoVonn H. Givens, Linda Kluge, Tracy Rutland, Adam Atherly, and Debra Saliba, “Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes, and Costs,” Journal of the American Geriatrics Society 58:627-635, 2010.  The study identified “the iatrogenic illnesses that can occur in hospitalized older adults (such as delirium, complications of immobility, injurious falls, indwelling bladder catheter-associated urinary tract infections, and polypharmacy and related adverse drug reactions).”
[3] Agency for Healthcare Quality and Research, 2010 National Healthcare Quality Report page 7-6 (March 2010).
[4] Medicare Payment Advisory Commission, Report to Congress: Medicare Payment Policy 167 (March 2010).
[5]The Center has extensive materials about observation status.  See http://www.medicareadvocacy.org/medicare-info/observation-status/.
[6]Henry Desmarais, “Financial Incentives in the Long-Term Care Context: A First Look at Relevant Information,” (Oct. 2010), http://www.kff.org/medicare/8111.cfm.
[7]  Michael Perry, Julia Cummings (Lake Research Partners), Gretchen Jacobson Tricia Neuman, Juliette Cubanski (Kaiser Family Foundation), “To Hospitalize or Not to Hospitalize? Medical Care for Long-Term Care facility Residents; A Report Based on Interviews in Four Cities with Physicians, Nurses, Social Workers, and Family Members of Residents of Long-Term Care Facilities (Oct. 2010), http://www.kff.org/medicare/8110.cfm.
[8]CMS, Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Phase II (Winter 2001).
[9] Subcommittee on Aging, Senate Committee on Labor and Human Resources, “Nursing Home Residents Rights: Has the Administration Set a Land Mine for the Landmark OBRA 1987 Nursing Home Reform Law?” pages 175-177, 102nd Cong., First Sess. (June 13, 1991).
[10]J.S. Kayser-Jones, Carolyn L. Wiener, and Joseph C. Barbaccia, “Factors Contributing to the Hospitalization of Nursing Home Residents,” The Gerontologist (1989).
[11] William H. Barker, James G. Zimmer, W. Jackson Hall, Brian C. Ruff, Charlene B. Freundlich, and Gerald M. Eggert, “Rates, Patterns, Causes, and Costs of Hospitalization of Nursing Home Residents: A Population-Based Study,” American Journal of Public Health, 1994; 84:1615-1620.
[12] Joseph G. Ouslander, Gerri Lamb, Mary Perloe, JoVonn H. Givens, Linda Kluge, Tracy Rutland, Adam Atherly, and Debra Saliba, “Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes, and Costs,” Journal of the American Geriatrics Society 58:627-635, 2010.
[13]  Kathleen Lourde, “Ramping Up for Higher Acuity; Nursing Facilities Respond to the Need for Reducing Hospitalizations,” page 21, Provider (Jan. 2011).
[14] Joseph G. Ouslander, Gerri Lamb, Mary Perloe, JoVonn H. Givens, Linda Kluge, Tracy Rutland, Adam Atherly, and Debra Saliba, “Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes, and Costs,” Journal of the American Geriatrics Society 58:627-635, 2010.