Implementation of a Standardized Discharge Process for Patients Transitioning from a Skilled Nursing Facility to the Community and Impact on Patient Preparedness for Discharge and Various Post-Discharge Medical Outcomes

Abstract Background Post-discharge deaths are common in patients hospitalized for sepsis, but the drivers of post-discharge deaths are unclear. The objective of this study was to test the hypothesis that hospitals with high risk-adjusted inpatient sepsis mortality also have high post-discharge mortality, readmissions, and discharge to nursing homes. Methods Retrospective cohort study of age-qualifying Medicare beneficiaries with sepsis hospitalization between January 2013 and December 2014. Hospital survivors were followed for 180-days post-discharge, and mortality, readmissions, and new admission to skilled nursing facility were measured. Inpatient hospital-specific sepsis risk-adjusted mortality ratio (observed: expected) was the primary exposure. Results A total of 830,721 patients in the cohort were hospitalized for sepsis, with inpatient mortality of 20% and 90-day mortality of 48%. Higher hospital-specific sepsis risk-adjusted mortality was associated with increased 90-day post-discharge mortality (aOR 1.03 per each 0.1 increase in hospital inpatient O:E ratio, 95% CI 1.03–1.04). Higher inpatient risk adjusted mortality was also associated with increased probability of being discharged to a nursing facility (aOR 1.03, 95% CI 1.02–1.03) and 90-day readmissions (aOR 1.03, 95% CI 1.02–1.03). Conclusions Hospitals with the highest risk-adjusted sepsis inpatient mortality also have higher post-discharge mortality and increased readmissions, suggesting that post-discharge complications are a modifiable risk that may be affected during inpatient care. Future work will seek to elucidate inpatient and healthcare practices that can reduce sepsis post-discharge complications.

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Influence of Context as a Key Ingredient for High Performance on Skilled Nursing Facility Readmissions

Innovation in Aging ◽

10.1093/geroni/igaa057.128 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 39-40

Author(s):

Roman Ayele ◽

Kirstin Manges ◽

Chelsea Leonard ◽

Marcie Lee ◽

Emily Galenbeck ◽

...

Keyword(s):

Organizational Context ◽

Contextual Factors ◽

Skilled Nursing Facility ◽

Adverse Outcomes ◽

Transitions Of Care ◽

Discharge Process ◽

Post Discharge ◽

Skilled Nursing ◽

High Performing ◽

Smooth Transitions

Abstract Improving hospital discharge processes and reducing adverse outcomes post discharge has become a topic of national importance, especially for older patients transitioning to skilled nursing facilities (SNFs). The substantial variation in rehospitalization outcomes suggests contextual factors may play a role in performance. We conducted rapid ethnography with opportunistic interviews (148 hours of observations, 30 clinicians) at hospitals that were high (n=2) or low (n=2)- performing in terms of their readmission rates from SNF, as well as 5 associated SNFs, to understand how contextual differences influenced performance variation. We used thematic analysis to categorize contextual factors and compare differences across high and low perfoming sites. We found three main contextual factors that differed across high- and low-performing hospitals and SNFs: team dynamics, patient characteristics, and organizational context. First, we observed high-quality communication, situational awareness, and shared mental models among team members in high-performing sites. Second, patients at high-performing hospitals had better insurance coverage that made it feasible for clinicians to place patients in SNFs based on their needs instead of financial abilities. Third, staff at high-performing hospitals were more engaged in the transitions process and rapport building with SNFs thereby facilitating smooth transitions of care from hospitals to SNFs. For example, clinicians at high- performing sites were actively engaged in directing the discharge process, but this was not observed in low-performing sites where a lack of clinician engagement lead to delays. Understanding how context affects transitions could be used to target organizational, policy, and staff level interventions to reduce adverse outcomes.

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Care transition to skilled nursing facility – A model and a case study

Journal of Hospital Administration ◽

10.5430/jha.v8n3p38 ◽

2019 ◽

Vol 8 (3) ◽

pp. 38 ◽

Cited By ~ 3

Author(s):

Mohan Tanniru ◽

Jacqueline Jones ◽

Samer Kazziha ◽

Michelle Hornberger

Keyword(s):

Patient Care ◽

Nurse Practitioners ◽

Skilled Nursing Facility ◽

Care Quality ◽

Care Transition ◽

Care Providers ◽

Post Discharge ◽

Nursing Facility ◽

Skilled Nursing

Background: Healthcare providers have focused on improving patient care transitions to reduce unanticipated readmission costs, improve patient care quality post-discharge and increase patient satisfaction. This is especially true in US since the introduction of the Affordable Care Act. While there are several practices and evidence-based programs discussed in the literature to address care transition post-discharge, the key challenge remains the same – how to structure the care transition program to influence its effectiveness. In this paper, we focus on modeling one particular care transition – moving a patient from a hospital to a skilled nursing facility (SNF) – and discuss how improved capacity building and use of intermediaries such as advanced nurse practitioners have shown promise in reducing patient readmissions.Method: The methodology proposed here uses service dominant (SD) logic research to inductively derive a model for service exchanges between the two provider ecosystems. This model is then used to analyze service gaps and look for opportunities to innovate within an SNF and improve its capacity to deliver care. Use of intermediation that expands the service model with the addition of more care providers besides the hospital and SNF is also discussed to reduce patient readmissions. Results: The study demonstrates that a number of actors have to work collaboratively to make care transition effective in meeting the patient and provider goals. Specifically, when two care facilities, hospital and SNF, are involved in care transition, opportunities exist to improve their internal capacity to address care within and across facilities. Conclusion: The paper makes two important contributions. It shows the role of SD Logic in identifying opportunities for service innovations in support of care transition, and it shows the role of actors in provider-customer ecosystems to make the transition effective.

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Payment drivers in Medicare patients undergoing total ankle arthroplasty

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00196 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0019

Author(s):

Daniel Cunningham ◽

Samuel Adams ◽

Mark Easley ◽

Vasili Karas ◽

James DeOrio

Keyword(s):

Skilled Nursing Facility ◽

Wound Complications ◽

Post Discharge ◽

Patient Factors ◽

Nursing Facility ◽

Skilled Nursing ◽

Ankle Arthroplasty ◽

Bundled Payment ◽

Patient Profile ◽

Ed Visits

Category: Ankle Arthritis Introduction/Purpose: The Comprehensive Care for Joint Replacement model (CJR) provides bundled payments for in-hospital and 90-day post-discharge care of patients undergoing total ankle arthroplasty (TAA). Defining patient factors associated with increased costs during TAA could help refine patient selection strategies and identify modifiable preoperative patient factors that can be addressed prior to the patient entering the bundle. Methods: This study is part of an IRB-approved single-center observational study of patients undergoing TAA from 1/1/2012 to 12/15/2016. Patients were included if they met CJR criteria for inclusion into the bundled payment model and had Medicare as the insurance payer. Costs related to readmissions, diagnosis, and procedures that had been excluded by CJR were also excluded from this financial analysis. All inpatient and outpatient payments beginning at the index procedure through 90 days postoperatively were identified. Patient medical profile including Charlson-Deyo and Elixhauser comorbidity scores, preoperative comorbidities, and perioperative factors were then completed based on institutional data and chart review. Additionally, post-discharge disposition, readmissions, emergency department (ED) utilization, and outpatient plastic surgery consultation were recorded within the 90-day bundled payment period. Results: Out of 199 patients with Medicare payments in the study timeframe, 137 had consented to the study and were analyzed. Baseline and operative characteristics are given in Table 1. Increased length of stay (LOS) at the initial procedure, increased Charlson-Deyo comorbidity score, cerebrovascular disease, and peripheral vascular disease were significantly associated with higher payments. Discharge to skilled nursing facility (skilled nursing facility), admissions, ED visits, and wound complications were significant drivers of payment. Conclusion: Increased Charlson-Deyo score and vascular disease along with increased LOS were associated with increased payments from Medicare. Discharge to SNF, readmission, ED visits, and wound complications considerably increased payments. This study identifies the relationship between patient profile and increased financial burden, highlighting the potential utility of pre-operative mitigation of modifiable risk factors and stratification of payments based on patient profile. Lastly, reducing rates of SNF placement, readmission, ED visitation, and wound complications are targets for decreasing costs for patients undergoing TAA.

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1158. Discontinuation of Urine Cultures by Infection Preventionists in Hospitalized Patients with Indwelling Urinary Catheters: Is It Safe?

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1021 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S414-S414

Author(s):

Cherie Faith Monsalud ◽

Rachel Lim ◽

Shane Zelencik ◽

Kamaljit Singh

Keyword(s):

Chart Review ◽

Skilled Nursing Facility ◽

Urinary Catheters ◽

Post Discharge ◽

Nursing Facility ◽

Skilled Nursing ◽

Tract Infections ◽

Healthcare Associated ◽

Urine Testing ◽

Infection Preventionists

Abstract Background A majority of healthcare-associated urinary tract infections (UTIs) are caused by the use of urinary catheters (CAUTI). Finding of bacteriuria is common in catheterized patients and often leads to unnecessary antibiotic treatment, increased length of stay and additional healthcare costs. We implemented an innovative intervention to improve urine culture (UCx) orders and prevent overdiagnosis of CAUTIs. Methods Orders for UCx in adult patients with short-term urinary catheters at NorthShore University HealthSystem, IL were reviewed daily for appropriateness based on the Infectious Diseases Society of America Guidelines. Appropriate urine testing was defined as: (1) presence of fever ( >38°C) within past 48 hours, (2) new urinary complaints: flank or suprapubic pain/tenderness or dysuria, frequency, urgency or incontinence within 48 hours after catheter removal, and (3) no other reasonable explanation for fever. If UCx was deemed inappropriate, ordering provider was contacted to cancel the order. Chart review was performed at least 30-days post-discharge to determine whether patients developed recurrent UTI, sepsis, were readmitted or expired. Results Between 1 January to 31 March 2019, 65 UCx were submitted. Sixty-four patients (98%) did not meet criteria for testing. Most common reasons for not meeting criteria were absence of fever (60%) and no localizing UTI signs or symptoms (57%). 35 (54%) UCx were canceled after discussion with ordering providers. 21/35 patients (60%) were treated with antibiotics. All 35 patients were discharged, with a majority going to a skilled nursing facility (34%) or home (31%). 4/35 (11%) had a subsequent positive UCx. Two patients developed symptomatic UTI (sUTI) during the index admission. Two patients developed sUTI within 30-days post-discharge; one patient was transitioned to hospice after completion of therapy. All 4 patients were treated for sUTI. Conclusion We were able to safely discontinue UCx in 89% of patients. A majority of patients were already started on empiric treatment and development of subsequent sUTI was infrequent (11% of patients). Our findings suggest that discontinuation of inappropriately ordered UCx is safe with low risk for sepsis or mortality. Disclosures All authors: No reported disclosures.

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Intern Transitions of Care Curriculum Through Posthospital Home and Skilled Nursing Facility Visits

Journal of Graduate Medical Education ◽

10.4300/jgme-17-00499.1 ◽

2018 ◽

Vol 10 (4) ◽

pp. 442-448 ◽

Cited By ~ 1

Author(s):

Rachel K. Miller ◽

Shimrit Keddem ◽

Samuel Katz ◽

Zachary Smith ◽

Christina R. Whitehouse ◽

...

Keyword(s):

Home Visit ◽

Skilled Nursing Facility ◽

Transitions Of Care ◽

Discharge Process ◽

Nursing Facility ◽

Skilled Nursing ◽

Team Members ◽

Care Experience ◽

Home Care Nurse ◽

Medical Histories

ABSTRACT Background Transitions of care pose significant risks for patients with complex medical histories. There are few experiential medical education curricula targeting this important aspect of care. Objective We designed and tested an internal medicine transitions of care experience integrated into interns' ambulatory curriculum. Methods The program included 1-hour group didactics, a posthospitalization discharge visit in pairs with a home care nurse (cohort 1: 2011–2012; cohort 2: 2012–2013), and a half-day small-group visit to a skilled nursing facility led by a faculty member in geriatrics (cohort 2 only). Both visits had structured debriefings by faculty in geriatrics. For cohort 1, a quantitative follow-up survey was administered 18 to 20 months after the experience. For cohort 2, reflections were analyzed. Results Thirty-three of 42 second-year residents (79%) in cohort 1 who participated in didactics and a home visit completed the survey. Seventy-six percent (25 of 33) reported increased knowledge of interprofessional team members' roles and the discharge process for patients with complex medical histories. Seventy-nine percent (26 of 33) reported continued use of medication reconciliation at discharge, and 64% (21 of 33) reported the experience enhanced their ability to identify threats to transitions. Of cohort 2 interns, 88% (42 of 48) participated in the home visit and 69% (33 of 48) in the skilled nursing facility visit. Intern reflections revealed insights gained, incomprehensive discharge plans, posthospital health care teams, and patients' postdischarge experience. Conclusions An experiential transitions of care curriculum is feasible and acceptable. Residents reported using the curriculum 18 to 20 months after exposure.

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Malpractice & Negligence: Cal. Supreme Court Clarifies Negligence Provisions under State’s Elder Abuse Act

The Journal of Law Medicine & Ethics ◽

10.1017/s1073110500012973 ◽

1999 ◽

Vol 27 (2) ◽

pp. 203-203

Author(s):

Kendra Carlson

Keyword(s):

Health Care ◽

Supreme Court ◽

Health Care Providers ◽

Elder Abuse ◽

Skilled Nursing Facility ◽

Pressure Sores ◽

Care Providers ◽

Nursing Facility ◽

Skilled Nursing ◽

The Supreme Court

The Supreme Court of California held, in Delaney v. Baker, 82 Cal. Rptr. 2d 610 (1999), that the heightened remedies available under the Elder Abuse Act (Act), Cal. Welf. & Inst. Code, §§ 15657,15657.2 (West 1998), apply to health care providers who engage in reckless neglect of an elder adult. The court interpreted two sections of the Act: (1) section 15657, which provides for enhanced remedies for reckless neglect; and (2) section 15657.2, which limits recovery for actions based on “professional negligence.” The court held that reckless neglect is distinct from professional negligence and therefore the restrictions on remedies against health care providers for professional negligence are inapplicable.Kay Delaney sued Meadowood, a skilled nursing facility (SNF), after a resident, her mother, died. Evidence at trial indicated that Rose Wallien, the decedent, was left lying in her own urine and feces for extended periods of time and had stage I11 and IV pressure sores on her ankles, feet, and buttocks at the time of her death.

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