SNF visits help hospital reduce LOS, readmissions

Patients transferred as soon as they’re stable

A program at the University of Michigan Health System in which physicians and nurse practitioners visit patients after their transfer to a skilled nursing facility has smoothed transitions and reduced the average length of stay of older patients from 10.6 days to eight days.

Hospital inpatient stays for patients in the program dropped by nearly 2,908 days a year after the program began, according to geriatric physician Darius K. Joshi, MD, who leads the UMHS sub-acute program at the 914-bed tertiary care center in Ann Arbor, MI. In addition, the number of patients readmitted within 15 days dropped from 20% to 17.4%.

“This program started before the CMS readmission reduction program, but preventing a return to the hospital has always been a priority for our hospital. The patients targeted for the program often come back to the emergency department. We operate at near capacity, and many times we have patients in the emergency department waiting for inpatient beds,” Joshi says.

The subacute program staff, which include physicians and nurse practitioners, are employed by the health system’s department of geriatric medicine and work on salary. “Their salaries and bonuses are not directly correlated to the number of patients a clinician sees and bills insurance for but are tied to programmatic goals like decreasing the hospital length of stay, decreasing hospital ‘bounce back’ of skilled nursing facility patients, and caring for complex, higher-acuity patients in the skilled nursing facility,” Joshi says.

In the past, many patients who are now being followed in skilled nursing facilities by the subacute service clinicians had lengthy hospital stays because they couldn’t safely be discharged to home, he says. In addition to freeing up beds for other patients by transferring hospital patients to a skilled nursing facility, the program has also helped prevent emergency department visits and readmissions, he adds.

“Before we started this program, when we discharged patients to skilled nursing facilities we had no contact with the physicians or other clinicians who were taking care of patients after they were discharged from acute care. Because of the lack of coordination between levels of care, the bounce-back for patients in skilled nursing facilities typically is very high,” Joshi says.

Many times, skilled nursing facility physicians make the decision to transfer patients back to the hospital after talking to the nurse on the telephone, rather than making a bedside visit, Joshi points out.

Physicians treating patients in skilled nursing facilities often have sketchy details about the patients’ hospital stays, Joshi says. “This lack of clinical coordination and communication can lead to adverse clinical outcomes as well as confusion and frustration for the patient and family members,” he says. In addition, he points out, most nursing homes contract with physicians in private practice who have a busy office practice and can’t see skilled nursing facility patients on a frequent basis.

“The physicians in our subacute program work full time in the skilled nursing facility. They don’t see patients in the office but focus their entire day on patients in the skilled nursing facilities. The more time physicians spend at the patient’s bedside, the less likely the patient is to need to be readmitted to the hospital,” he says.

Working with the hospitalist team and the surgeons, the subacute care team identifies patients who, in the past, would stay in the hospital after they were stabilized, rather than being transferred to a skilled nursing facility to recover. Hospitalists and surgeons feel more comfortable discharging patients to a skilled nursing facility because they know one of their colleagues from the same health system is following the patient after discharge, he says.

“Patients in the program are those who no longer require intensive care after a few days in the hospital. They are relatively medically stable, but not ready to be discharged to home,” Joshi says.

For instance, an 85-year-old patient with pneumonia who requires IV antibiotics for several weeks and becomes confused while in the hospital typically stays in the hospital until the confusion is resolved and he or she has finished with the course of antibiotics. “In this program, once we feel the patient’s respiratory condition has stabilized and they are breathing better, we transfer them to a subacute facility that can provide care and rehabilitation. Elderly patients do quite well in this situation,” Joshi says.

The subacute team doesn’t usually see patients in the hospital setting unless they are called in to assess a patient’s eligibility for the program. They are alerted when patients are transferred from the acute care hospital to a skilled nursing facility.

The program operates seven days a week. Physicians and nurse practitioners round on their patients Monday through Friday at the skilled nursing facilities and rotate weekend duty. They see any patients being transferred to skilled nursing facilities within 24 hours of their hospital discharge.

The health system has an extensive electronic medical record that gives the physicians and nurse practitioners on the subacute service Internet access to information on the patients from all levels of care.

“The biggest challenge for physicians in private skilled nursing facilities is that they don’t know what has been happening with patients before they come to the skilled nursing facility. This program makes the privately owned skilled nursing facility an extension of the hospital,” he says.

When patients are transferred to a skilled nursing facility, a nurse practitioner from the program conducts medical reconciliation in the facility. “Many skilled nursing facilities still use paper records, and we find a lot of medication errors. The nurse practitioner reviews the medication for every patient every week,” he says.

To ensure continuity of care after patients are discharged from the skilled nursing facility, the team works closely with patients’ primary care providers and makes sure they have details about the acute care and skilled nursing stay.