2008 Conference

Planning Committee

The conference held on September 24, 2008 was a success. Over 340 participants from across the continuum of care attended. The evaluations indicated that 94% of the attendees rated the program from good to excellent.

Picture of the Planning Committee

"Person-Centered Transitions of Care: Challenges and Successes for Discharge Planning Across the Continuum" Conference Planning Committee: back, l to r, Elliott Frost, NYAHSA, Lisa Newcomb, ESAALF, Andy Koski and Lynda Schoonbeek, NYSHCA, Sara Butterfield, IPRO, Margaret Clark, HCP of NYS, seated, Nancy Leveille, NYSHFA, Anna Colello, Esq, NYSDOH, Anita Russo, ESAALF, missing, Deb LeBarron, HANYS, Scott Jackson, NYSHFA. Photo credit: Mike Wren

Improving the Movement of Difficult-to-Place Patients Between Hospitals and Nursing Homes: A Follow-up Study

NOTE: To view the article with Web enhancements, go to: http://www.medscape.com/viewarticle/528804

Ronald J. Lagoe, PhD; Saundra E. Mnich, MSN, RNC; Mary Luziani, BS, RN; Lynn M. Winks, RN, ACM 
Topics in Advanced Practice Nursing eJournal. 2006;6(1) © 2006 Medscape
Posted 04/12/2006

Abstract and Introduction

Abstract

Context: The challenge of providing appropriate and efficient care to elderly patients with chronic diagnoses is confronting hospitals and long-term care facilities as populations age and healthcare resources are limited.

Objective: This study described the results of the first 4 years of implementation of a series of programs to improve the movement of patients from hospitals to nursing homes.

Desired Outcomes: The programs were designed to increase the accessibility of nursing homes to difficult-to-place hospital patients, including those requiring subacute services.

Setting: The study involved the 4 acute hospitals and 12 nursing homes operating in the metropolitan area of Syracuse, New York, with a population of 451,366.

Principal Outcome Measures: The principal measures included the number of difficult-to-place patients admitted to nursing homes each year; total number of new admissions to nursing homes each year; and the number of intravenous therapy, high-cost oral medication, and subacute service patients admitted to nursing homes each year.

Results: In the initial 4 years of program implementation, between 2002 and 2004, an annual increase of 7.5% (100 patients) in annual admissions of difficult-to place-patients to nursing homes occurred. This increase was produced by 6 of the 12 area nursing homes combined. This increase was supported by a 40% increase in total admissions to nursing homes across the community. The increase was produced by a combination of 6 nursing homes. For 4 other facilities, difficult-to-place admissions from hospitals declined. The project was also supported by the development of 4 subacute services in nursing homes.

Conclusions: The study demonstrated that it is possible to increase the movement of chronic-care difficult-to-place patients from hospitals to nursing homes through a community-wide program.

Introduction

Maintaining continuity of care between hospitals and nursing homes has been a growing challenge in communities throughout the United States. Developing appropriate care arrangements for hospital patients who require long-term placement in nursing homes, rather than short-term rehabilitation, has become a major challenge. In many communities, these patients have experienced extended stays in short-term acute care facilities before gaining access to the residential care that they need.[1]

A variety of approaches have been employed to expedite the movement of hospital patients to long-term care. During the 1980s, community care demonstration programs attempted to coordinate care among hospitals, nursing homes, and home care agencies. Despite some successes, these mechanisms did not have a major impact on hospital utilization for patients requiring long-term stays in nursing homes.[2,3]

Since that time, other approaches to coordinating hospital discharges and nursing home admissions have been developed involving disease management or individual provider networks. The results of these efforts have been mixed, although network models have generated some promise through their control of all participating providers.[4,5]

Trends in demographics suggest that the challenge posed to systems by elderly hospital patients who require long-term placement in nursing homes will increase. As local and regional populations continue to age, community hospitals will need to place more of these patients in long-term care services in order to maintain access throughout the continuum of care.[6,7

Delays in placement will limit access to emergency departments and acute care and generate added hospital expenses without corresponding revenue.[8,9] This situation could become most difficult in areas with large elderly populations who lack extensive private resources and who are reimbursed by Medicare and Medicaid.

Governmental economic pressures could make this situation more difficult. In recent years, the federal budget, which includes the Medicare program, has been burdened by international commitments, domestic disaster relief, and other obligations.[10] State and local budgets, major sources of Medicaid funding for long-term care expenses, have been limited by stable revenues and reduced economic growth.[11]

In many communities, the ability of hospitals to develop long-term placements for elderly patients has also been limited by the competitive nature of healthcare. Network arrangements have improved the movement of patients between individual facilities but have restricted access to nursing homes between systems of care.[12] Widespread interest in financially advantageous surgery programs has diverted the attention of hospitals and nursing homes from the adult medicine population, the source of most difficult-to-place patients. The result of these developments has frequently been a disproportionate interest in groups who require short-term rehabilitation and reduced attention to those who do not.[13]

This study is a follow-up evaluation of a program to expedite the movement of difficult-to-place patients from hospitals to nursing homes in Syracuse, New York. It describes how hospitals and nursing homes in the community cooperated to address this problem amid the organizational, clinical, and financial challenges that confront this group in many areas of the nation. It identified approaches that generated progress in providing appropriate care for this population, as well as obstacles that remained to be addressed.

Historically, the hospitals and nursing homes of Onondaga County have worked cooperatively to expedite the movement of patients between these settings of care. Demonstration programs that were implemented in 1987 and 1999 addressed this objective. These programs were supported by increased hospital interest in reducing stays for discharges to nursing homes generated by the transition of acute care facilities from per diem to per discharge reimbursement during the late 1980s in New York State. These efforts did not, however, result in the development of a permanent program to address this need.[14,15]

As reported in the study that described the development of this project, studies by the Hospital Executive Council in 2001 and 2002 demonstrated that substantial numbers of excess hospital patient days were being generated in Syracuse compared with severity-adjusted national averages. The data indicated that the largest source of these excess days was discharges to nursing homes. The data also suggested approximately 25.4% of hospital discharges to long-term care facilities were responsible for 59.9% of the excess days for this patient status.[16]

Population

The study describes a follow-up evaluation of a cooperative program to expedite the movement of difficult-to-place patients in the metropolitan area of Syracuse, New York. This area includes the City of Syracuse and Onondaga County. In 2005, the area had a total population of 451,366, of which 14.1% was aged 65 years or older and 4.6% was aged 80 years or older.

The City of Syracuse and Onondaga County have 4 general hospitals that generated a total of 73,992 inpatient discharges in 2004. These acute care facilities include Community-General Hospital (10,174 discharges), Crouse Hospital (21,802 discharges), St. Joseph's Hospital Health Center (25,296 discharges), and University Hospital of the State University of New York Upstate Medical University (16,720 discharges).

The area includes 12 skilled nursing facilities that operate a total of 2929 beds. Sixty-two percent of this capacity is located in 4 facilities: Loretto (556 beds), Van Duyn Home and Hospital (526 beds), James Square Health and Rehabilitation Center (455 beds), and St. Camillus Health and Rehabilitation Center (290 beds). Between 2002 and 2004, the number of admissions to these nursing homes from the 4 Syracuse hospitals increased by 29%, from 3933 to 5081.

The increase in hospital discharges to nursing homes has been the major driver of efforts to improve the movement of patients between these levels of care. Between 2002 and 2004, adult medicine discharges from the combined Syracuse hospitals increased by 6.4%, from 24,207 to 25,748, while adult surgery discharges increased by 4.1%, from 18,372 to 19,129. During the same period, total hospital discharges remained constant or declined for all other services. During 2005, the impact of the adult medicine population increased. Between January 2004 and October 2005, total discharges for this group increased by 6.5%, while adult surgery discharges declined by 0.1%.

Methods

During 2002, representatives of the Syracuse hospitals and local nursing homes developed a series of community-wide programs to address the needs of difficult-to-place patients. This process was carried out through the Hospital Executive Council and the Long Term Care Executive Council, the planning organizations for the 2 groups of providers. This process resulted in the development of a System Efficiency Project to address the needs of all difficult-to-place patients and a group of subacute programs to address the needs of those with specific clinical needs.[16]

For purposes of the community-wide System Efficiency Project, difficult-to-place patients were defined according to the following general criteria:

  • Chronic, long-term, nonsurgical diagnoses;
  • Minimal rehabilitation potential;
  • Surgical procedures requiring long-term recovery;
  • Lack of family supports;
  • Lack of home environment;
  • Pending Medicaid status; and
  • No secondary long-term care payer.

Because the inpatient populations and the service configurations of the Syracuse hospitals varied, care managers within each of the hospitals could modify the criteria to address utilization within their institutions. The community-wide System Efficiency Project also involved the movement of patients desirable to nursing homes. It was recognized that the definitions of these patients vary among providers. Although these characteristics vary, they generally included the following:

  • Extensive rehabilitation potential;
  • Short-term nursing home stays;
  • Supportive home environments; and
  • Private pay or approved Medicare or Medicaid.

Evaluation of the project included a background analysis of demographic and clinical factors for discharges to nursing homes in Syracuse between 2002 and 2005. This analysis indicated that characteristics of the study populations had remained relatively constant. The average age increased by less than 1%, from 75.94 to 76.11 years. The percentage of the female population declined by fewer than 2 points, from 66.7% to 64.2%. The mean severity of illness, measured by the 3M All Patients Refined DRG System, declined from 2.5267 to 2.5229.

The community-wide System Efficiency Project was implemented in January 2003. This initiative was designed as a mechanism that linked nursing home efforts to admit larger numbers of difficult-to-place patients from hospitals with hospital efforts to identify larger numbers of patients attractive to nursing homes. The hospital efforts focused on identifying these patients earlier in their acute-care stays in order to provide nursing homes with more opportunity to plan for these admissions. The planning for implementation of the System Efficiency Project assumed that nursing homes that admitted difficult-to-place patients at higher rates would receive more referrals of attractive patients.[16

The System Efficiency Project was designed to address the needs of patients requiring long-term-care services among all hospitals and nursing homes in the Syracuse metropolitan area, as well as within a number of networks that had developed between individual hospitals and long-term-care facilities. In a sense, the initiative was designed to create additional relationships between providers by encouraging increases in the movement of difficult-to-place and attractive patients between individual hospitals and nursing homes.[16]

The distribution of data became a major component of the effort. From initial implementation, each of the Syracuse hospitals identified difficult-to-place patients on an ongoing basis. A list of difficult-to-place patients in each of the Syracuse hospitals was sent by email to all area nursing homes, assisted-living programs, and home health agencies by the Hospital Executive Council twice each week. The list of difficult-to-place patients identified the encrypted hospital account number, the admission date, major long-term-care diagnoses, and number of nonacute days for each patient.

Nonacute days (also called alternate-care days in New York State) are defined as patient days produced after the conclusion of the acute stay, in the absence of nursing home admission. The difficult-to-place patients included the nonacute patients and candidates for this status identified by hospital care managers. When these patients were discharged, the discharge status and facility destination of each was also identified. This information was available to all participants in the program.

The distribution of the list of difficult-to-place patients was approved by the Institutional Review Boards of the Hospital Executive Council and the Long Term Care Executive Council. In these lists, patients were identified by encrypted numbers. This made it impossible to identify individual patients from the data provided. The approvals of the Hospital Executive Council and the Long Term Care Executive Council Institutional Review Boards were also obtained for the distribution of provider-specific utilization data in the projects.

A summary tabulation of numbers of difficult-to-place patients admitted to nursing homes, as well as total new admissions from hospitals and rates of difficult-to-place admissions per total new admissions was also sent to all hospitals and nursing homes in the community. This distribution was carried out on a monthly basis by the Hospital Executive Council through email. Like the difficult-to-place patient lists, this information was available to all participants in the program. The approvals of the Hospital Executive Council and the Long Term Care Executive Council Institutional Review Board were also obtained for distribution of this information.

For the electronic distribution of patient-specific data and the distribution of summary tables, hospitals and nursing homes were identified. The decision to provide this information was made by the Hospital Executive Council and the Long Term Care Executive Council in order to encourage accountability for the movement of patients. The distribution of data with provider-specific information made the progress of the program transparent for the entire community. This approach was consistent with other programs for the distribution of provider-specific data which had previously been implemented in the Syracuse metropolitan area. These programs include data for hospitals, nursing homes, and emergency medical services. [17]

The System Efficiency Project was designed as a general framework to expedite the movement of patients between hospitals and nursing homes. During the development of this project, it was recognized that individual hospitals and nursing homes had previously implemented cooperative programs in this area. It was also recognized that specific programs would continue to be implemented. For this reason, the System Efficiency Project was designed as an overall framework with data feedback, rather than a series of specific clinical and administrative mechanisms. Participating hospitals and nursing homes were encouraged to develop specific mechanisms to support the implementation of the program. Because of differences and internal policies of the competing hospitals and nursing homes, it was not possible to provide a list of these activities.

The only specific community-wide clinical programs that were developed in relation to the System Efficiency Project were a series of subacute programs in long-term-care facilities. These services were designed to address specific obstacles to the movement of difficult-to-place patients that had been identified by the hospitals. They included intravenous therapy, high-cost oral medications, and extensive wound care.

The subacute services were structured within similar frameworks to ensure compliance with legal guidelines and ease of administration. Patients were identified by hospital care managers and nursing home admissions staff. In order to qualify for the program, the need for intravenous therapy, high-cost oral medications, or extensive wound care services needed to be documented within the hospital as the principal obstacle to nursing facility admission. A coordinator at each hospital was responsible for confirming this situation. For each patient admitted to a subacute program, the hospitals provided program development funding. To ensure compliance with legal guidelines, this funding was allotted at a single, community-wide rate, without regard to the specific characteristics of each patient. The program was administered and funding was distributed from a community-wide pool by the Hospital Executive Council.

The subacute programs were implemented on a sequential basis in Syracuse. The intravenous-therapy program was initiated in February 2003 and involved 3 nursing homes. The high-cost oral medications program was implemented in April 2004 and included 5 nursing homes. The extensive wound-care program was implemented in November 2004 and included 1 nursing home because of the projected small volume of patients. Each of the programs included all 4 Syracuse hospitals.

Funding for the proposed project was provided by the hospitals and nursing homes of Onondaga County through financial support for the Hospital Executive Council and the Long Term Care Executive Council and through the activities of hospital care managers and nursing home admission staff. The project was incorporated within the activities and operating budgets of all of the participating organizations. The only additional funding provided for the projects involved the program development funds for the subacute programs that were generated by the hospitals and distributed by the Hospital Executive Council.

Results

The follow-up study included results of implementation of the System Efficiency Project during a 3-year period. It also included results of implementation of each of the subacute programs.

For the System Efficiency Project, the results of the program focused on the following research and operational objectives:

  • Increased admission of difficult-to-place patients to nursing homes;
  • Increased early identification of patients desirable to nursing homes by hospitals resulting in increased nursing home admissions of this group; and
  • Reduction of hospital lengths of stay for patients discharged to nursing homes through accomplishment of the first 2 objectives.

Evaluation of the project focused on these utilization objectives. Additional measures, including clinical care, patient satisfaction, and social conditions, were not evaluated. Because resources of the project were limited to the existing staff of the Hospital Executive Council and the Long Term Care Executive Council, additional funding did not exist to support detailed evaluation of these factors.

The System Efficiency Project was implemented in January 2002. Data for the combined Syracuse hospitals and nursing homes for the first 4 years of implementation of this effort are summarized in Table 1 .

With respect to the first objective, the information in Table 1 demonstrates that the increased nursing home admissions of difficult-to-place patients from the Syracuse hospitals occurred during the initial years of the project. Total difficult-to-place admissions increased by 7.1% between 2002 and 2004, from 822 to 880.

With respect to the second objective, during the same period, the admission of non-difficult-to-place patients, many of whom required short-term rehabilitation, increased by 47.4%, from 3840 to 5661 per year. The combined population, including all hospital admissions to nursing homes, increased by 40.3% during this period. These data demonstrated that the increase in the non-difficult-to-place population was more than 6 times greater than the increase in the difficult-to-place group. As a result, the difficult-to-place admission rate per new admissions from hospitals declined from 17.6% to 13.5% during this period. The change in rates was not significant at the .05 level.

With respect to the third objective, the data also demonstrated that mean lengths of stay for all discharges to nursing homes from the Syracuse hospitals declined during this period. The reduction in the mean length of stay between 2002 (11.1 days) and 2005 (8.9 days) amounted to 2.2 days. This community-wide change was significant at the .05 level. When applied to the discharge volume for 2005, this generated an annual savings of 14,390 patient-days, or an average daily census of 39.4.

A review of these data suggested that, at the community-wide level, the Syracuse Efficiency Project had the intended impact. The nursing homes in the community admitted larger numbers of difficult-to-place patients. In order to support the resources needed by this population, hospital staffs directed additional numbers of attractive, non-difficult-to-place patients to facilities. The magnitude of the increase in non-difficult-to-place patients to nursing homes was substantial. The study did not, however, evaluate the financial costs of the difficult-to-place admissions or the financial benefits of the non-difficult-to-place admissions to long-term-care facilities.

The follow-up study also included evaluation of System Efficiency Program utilization for individual nursing homes. Data concerning the facilities with high performances under the initiative are summarized in Table 2 .

This information demonstrated that 6 nursing homes in the community were accepting at least 15% of new admissions from hospitals as difficult-to-place patients by 2005. By sponsorship, these facilities included 4 private nonprofit facilities (Iroquois, Loretto, Rosewood Heights, and Vivian Teal Howard), 1 proprietary facility (The Crossings), and 1 government-operated facility (Van Duyn). Two of the private nonprofit facilities (Iroquois and Rosewood Heights) were owned by the Syracuse hospitals.

The data indicated that total difficult-to-place patients admitted by these 6 facilities increased by 23% (101 patients) during the 4-year period. At the same time, total new admissions from hospitals increased by 43.0%, or 792 patients. Comparison of this information with the data in Table 1 demonstrates that these facilities accounted for all of the increases in difficult-to-place admissions during the period of the study.

The data indicated that 5 of the 6 nursing homes, all except Vivian Teal Howard, had produced increases in annual admissions of difficult-to-place patients during the 4-year period. Loretto, a large private nonprofit with a history of working with the Syracuse hospitals, accepted 35% of the total difficult-to-place admissions for the 6 facilities. Rosewood Heights, a hospital-owned facility with an orientation toward chronic-care patients, accepted 21.7% of the difficult-to-place admissions for the 6 facilities.

The data also indicated that in 4 of the nursing homes with increases in difficult-to-place admissions between 2002 and 2005 -- Iroquois, the Crossings, Van Duyn, and Vivian Teal Howard -- rates of admission of difficult-to-place patients declined. This occurred because percentage increases in total new admissions exceeded percentage increases in difficult-to-place admissions. At The Crossings and Rosewood Heights, difficult-to-place admission rates increased when changes in difficult-to-place admissions increased, while total new admissions rose by a lower rate or declined. These changes reflected a variety of circumstances related to access to patients and organizational objectives of individual nursing homes.

The follow-up study also included evaluation of System Efficiency Project utilization for nursing homes with relatively low difficult-to-place admission rates. Data for these facilities are summarized in Table 3 .

This information demonstrated that 3 of the nursing homes in the Syracuse metropolitan area were generating difficult-to-place admission rates of 10% or less by 2005. These providers included 3 private nonprofit facilities (the Jewish Home, St. Camillus, and the Syracuse Home Association) and 2 proprietary facilities (Birchwood and Sunnyside).

The data in Table 3 indicated that the total number of difficult-to-place patients admitted by these facilities declined by 13.9% between 2002 and 2004, from 151 to 130. This volume increased by 9.2% between 2004 and 2005 after reaching a low point in 2004. During the same period, total new admissions from hospitals to these facilities increased by 44.0%.

The data also demonstrated that at 4 of the low-performing nursing homes -- Birchwood, the Jewish Home, St. Camillus, and Sunnyside -- the annual numbers of difficult-to-place patients declined between 2002 and 2004. Percentage declines varied widely among these facilities because of the small numbers of difficult-to-place admissions. The largest decline in annual numbers of difficult-to-place admissions, 14, occurred at St. Camillus.

The slight increase in the annual number of difficult-to-place admissions for the combined nursing homes between 2004 and 2005 may have been related to additional communication between the Hospital Executive Council and these facilities during the second half of 2005. In addition to monthly summary tables, letters were written to the administrators of these facilities which identified the problem and encouraged additional efforts to admit these patients. This increases in difficult-to-place admissions was produced by 2 facilities, St. Camillus and the Syracuse Home Association.

The research and operational objectives for the subacute services included the following:

  • Implementation of intravenous therapy, high-cost oral medications, and extensive wound-care programs in nursing homes;
  • Referral of hospital patients to subacute services in nursing homes in order to reduce hospital patient days; and
  • Provision of hospital program development funds to support subacute patients in nursing homes and increase efficiency of hospital inpatient care.

Utilization data for the subacute services implemented in the Syracuse metropolitan area are summarized in Table 4 . This information demonstrated that for each of these groups, hospital patient-days were avoided at limited cost.

The most important subacute service has involved intravenous therapy. The study data indicated that, in its first 3 years of operation, this project served 192 hospital inpatients, resulting in a savings of 4032 inpatient days. This program involved 3 nursing homes (Loretto, Rosewood Heights, and James Square) that had worked with the hospitals to develop training and consultation arrangements for their staffs. Utilization data from the service indicated that the patient population included individuals who had completed acute-care treatment, with the exception of intravenous therapy. These patients were also not candidates for home intravenous therapy because of their clinical condition, lack of social support, or reimbursement issues. On the basis of the estimated costs of the inpatient days avoided and the program development funds expended, the rate of return for this service was 16.2 to 1.

The data for subacute services also demonstrated that the high-cost oral medications program had served 112 patients since its implementation in February 2004, 13 months after the start of the intravenous-medications service. Five nursing homes (Loretto, Rosewood Heights, James Square, Iroquois, and The Crossings) participated in this initiative. Utilization of the service was limited by its focus only on specific high-cost oral medications rather than a level of care. Patient participation was monitored to ensure that the effort did not admit individuals whose medications were already reimbursed through existing nursing home rates. On the basis of the estimated costs of the inpatient days avoided and the program development funds expended, the rate of return for the service was 4.2 to 1.

The data for the extensive wound-care subacute service was limited because this program was implemented in January 2005. The service was implemented in 1 nursing home (Loretto). Because this initiative involved wound care and other substantial services, it had been anticipated that the service population would include a relatively small group of patients with extensive care needs. This was demonstrated by the fact that the initial population served avoided a mean additional hospital stay of 30 days. On the basis of the estimated costs of these days and the program development funds expended, the rate of return was 11.6 to 1.

Discussion

Recent experience and literature suggests that the care of patients with chronic medical conditions is a major challenge facing acute hospitals and nursing homes. The movement of these difficult-to-place patients to appropriate levels of care is required for optimum outcomes. It is also necessary to enable hospitals and other providers to maintain the capacity to serve populations at the community levels. Demographic data and the experiences of some communities suggest that the challenge of providing care to this population is increasing. As local populations continue to age, this challenge will become more formidable.

The programs described in this study were developed, in part, because of the lack of models in the literature that focused specifically on expediting the movement of patients between hospitals and nursing homes. While published literature contains extensive material concerning outcomes of care and related issues, it does not include studies that focus on efficiency of patient movement between levels of care. This point was supported by contacts with the authors from a number of consultants after publication of the original study.

This study was a follow-up evaluation of a series of programs to expedite the movement of difficult-to-place patients from hospitals to nursing homes in the metropolitan area of Syracuse, New York. The majority of this effort, the System Efficiency Project, involved identification of these patients by hospital staffs and efforts with all area nursing homes to generate more expeditious placements, in return for additional identification of patients attractive to these facilities. The study data indicated that, during its first 4 years, the effort made notable progress. The annual number of difficult-to-place patients admitted by nursing homes increased by over 7%, while total new admissions to nursing homes increased by over 40%. The data demonstrated that 6 nursing homes in the community absorbed all of the increase in difficult-to-place admissions.

This study also demonstrated that development of a series of subacute programs in the Syracuse metropolitan area had contributed to this effort for hospital patients requiring extended intravenous therapy, high-cost oral medications, and extensive wound care. Limited investments in program development of these services in nursing homes saved substantial numbers of patient days and generated financial rates of return between 4 and 16 to 1.

The follow-up study indicated that the development of a community-wide effort to improve the efficiency of care for difficult-to-place patients could be successful. It also identified the limitations of this approach. In Syracuse and Onondaga County, the additional 100 difficult-to-place admissions to nursing homes per year were generated between 2002 and 2004 by a combination of 6 facilities, including those with different sizes and sponsorships. These nursing homes accounted for half of the long-term-care facilities in the community. Four other nursing homes, also including a range of different sizes and sponsorships, produced a reduction in difficult-to-place admissions during the same period.

This dichotomy in nursing home admissions of chronic-care patients in Syracuse could create a real problem for the healthcare system during the next several years. Data from the follow-up study demonstrated that both the high-admittance and low-admittance difficult-to-place facilities increased their total new admissions from hospitals by over 40%. Therefore, the low-admittance facilities were shifting burden of this population to those with higher admission rates.

Discussions among hospitals and nursing homes in Syracuse suggest that this kind of shifting cannot be sustained indefinitely. Eventually, it will cause one or more of the high-admittance nursing homes to change its service pattern or go out of business. In response to this situation, the Syracuse hospitals and a number of nursing facilities are increasing their efforts to distribute admissions of difficult-to-place patients more equitably among area nursing homes. This effort has involved continued distribution of lists of these patients and monthly summary data, as well as additional contacts with low-performing nursing homes. It has also involved exploration of the potential for additional subacute programs in long-term-care facilities.

The next level of effort to support the movement of difficult-to-place patients in Syracuse is focusing on extension of a community conscious of responsibility for this population. At both the conceptual and quantitative levels, this will involve the development of community-wide support to influence nursing homes to admit additional chronic-care patients so that the entire healthcare system can continue to function. This process will be backed up by moral influence and continued distribution of utilization data.

The next phase of the project will also involve evaluation of the potential for additional subacute services in nursing homes. This process will focus on identification of services with the potential to improve the movement of difficult-to-place patients through the system, as well as the ability of nursing homes to operate these additional programs.

The authors concede that both the System Efficiency Project and the subacute services implemented in Syracuse focused on changes in utilization rather than on a detailed financial model. Because of differences in cost-accounting systems among hospitals and nursing homes in Syracuse, it was not possible to provide consistent evaluation of savings among providers. For this reason, evaluation of the impact of these programs focused largely on changes in numbers of placements, lengths of stay, and patient days as utilization indicators.

The same challenge of providing care for chronic-care patients that is being addressed in Syracuse is also being faced in communities throughout the United States and other countries. In an era of expanding need and limited resources, it will need to be addressed through a combination of caregiver responsibility and technical creativity. All healthcare systems will benefit through the implementation and evaluation of additional initiatives in this area.


Table 1. Difficult to Place and Alternate Care Nursing Home Placements: Syracuse Hospitals, 2002-2005
    2002     2003     2004     2005  
Difficult to place admissions including alternate care 822 874 765 880
Total non-difficult-to-place from hospitals 3840 4505 5288 5661
Total new admissions from hospitals 4662 5379 6053 6541
Difficult-to-place admission rate* 17.6 16.2 12.6 13.5
Mean hospital length of stay (days)**
Discharges to nursing homes
11.1 10.0 8.9 8.9
*Changes in the difficult to place admission rate were not significant at .05 level.
**Changes in the hospital mean length of stay were significant at .05 level.
Source: Hospital Executive Council data.


Table 2. Difficult to Place and Alternate Care Nursing Home Placements: High Performance Nursing Homes, 2002-2005
Nursing Home 2002 2003 2004 2005
DTP/ALC Adm Total New Adm Rate DTP/ALC Adm Total New Adm Rate DTP/ALC Adm Total New Adm Rate DTP/ALC Adm Total New Adm Rate
The Crossings 14 130 10.8 17 156 10.9 23 234 9.8 47 221 21.3
Iroquois Nursing Home 46 170 27.1 42 188 22.3 33 226 14.6 51 245 20.8
Loretto 203 940 21.6 237 1121 21.1 210 1252 16.8 216 1322 16.3
Rosewood Heights 74 271 27.3 90 284 31.7 111 385 28.8 133 410 32.4
Van Duyn Home and Hospital 68 230 29.6 63 245 25.7 58 306 19.0 70 359 19.5
Vivian Teal Howard 28 102 27.5 18 98 18.4 15 72 20.8 17 78 21.8
Combined Total 433 1843 23.5 467 2092 22.3 450 2475 18.2 534 2635 20.3
Source: Hospital Executive Council data


Table 3. Difficult to Place and Alternate Care Nursing Home Placements: Low Performance Nursing Homes, 2002-2005
Nursing Home 2002 2003 2004 2005
DTP/ALC Adm Total New Adm Rate DTP/ALC Adm Total New Adm Rate DTP/ALC Adm Total New Adm Rate DTP/ALC Adm Total New Adm Rate
Birchwood Health Care Center 38 617 6.2 43 695 6.2 31 719 4.3 31 780 4.0
Jewish Home of C.N.Y. 11 88 12.5 12 112 10.7 8 120 6.7 6 161 3.7
St. Camillus Hlth.Reh.Ctr. 78 710 11.0 107 820 13.0 55 883 6.2 64 874 7.3
Sunnyside Nursing Home 11 47 23.4 10 45 22.2 9 53 17.0 7 69 10.1
Syracuse Home Association 13 62 21.0 13 152 8.6 19 236 8.1 22 310 7.1
Combined Total 151 1524 9.9 185 1824 10.1 122 2011 6.1 130 2194 5.9
Source: Hospital Executive Council data.


Table 4. Subacute Program Utilization, Syracuse Hospitals
Program Number of Patients Patient Days Avoided Program Expenses ($) Cost of Patient Days Saved ($)
Intravenous medications program
(January 2003-September 2005)
192 4032 124,800 2,016,000
Oral medications program
(February 2004-September 2005)
112 784 56,000 235,200
Wound vac
(January 2005-September 2005)
19 570 38,000 285,000
Total 323 5386 218,800 2,536,200
Includes patients discharged from both acute and alternate care.
Source: Hospital Executive Council.

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Ronald J. Lagoe, PhD, Executive Director, Hospital Executive Council, Syracuse, New York,
Saundra E. Mnich, MSN, RNC, Director of Nursing Support Services, Upstate Medical University Hospital, Syracuse, New York,
Mary Luziani, BS, RN, Director, Care Management Services, St. Joseph's Hospital Health Center, Syracuse, New York,
Lynn M. Winks, RN, ACM, Director, Care Coordination Services, Crouse Hospital, Syracuse, New York

Disclosures:
Ronald J. Lagoe, PhD, has disclosed no relevant financial relationships.
Saundra E. Mnich, MSN, RNC, has disclosed no relevant financial relationships.
Mary Luziani, BS, RN, has disclosed no relevant financial relationships.
Lynn M. Winks, RN, ACM, has disclosed no relevant financial relationships.