Welcome And Important Disclaimer

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Hello, I will be your host. My name is Deanna Fi. I am a registered nurse and healthcare analyst. Let's get started.

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The views or opinions expressed in this podcast are for informational purposes only, not intended as legal or professional advice, and may not represent those of Verity Consulting. Although we make strong efforts to make sure our information is accurate at the time the podcast episode was recorded, Verity Consulting cannot guarantee that all information in this podcast is always correct, complete, or up to date. All information in this podcast is subject to change without notice.

Why Proactive Care Planning Matters

SPEAKER_01 0:49

Welcome back to the second part of the episode where we continue our discussion about emergency room admissions for nursing home residents and residents who are admitted to the hospital from nursing homes, and how we want to avoid those situations to the extent that they are possible. So the core message here is we really want to be proactive in our care planning and our early detection of clinical changes, and hopefully have effective facility management processes and systems in place to improve our resident well-being and overall reduce health care costs in those situations as well. So, some key points here. I want to go over are the goal, what are my goals for avoiding emergency room transfers? Why is it important to have good data tracking? I'll go over that. What's the importance of advanced care planning? I'll highlight some key points. I'll talk about some components related to hospital readmissions, discuss some historical initiatives that I was involved in with some CMS research on avoidable hospitalizations. I'll talk a little bit about leveraging some clinical tools and quality measures and how you can affect quality measures, and just kind of summarize some documentation and some best practices. Okay, let me get into it here. All right. Okay, so overall, we want to avoid sending residents to the emergency room. I don't know anyone who wants to go to the emergency room, as I've already talked about in the prior episode. So that's our overall aim. All right. So we know we have nursing facilities that have been uh struggling with this for decades. Uh hospitals are sending residents who are much sicker to the nursing facilities. Nursing facilities have been consistently training staff, educating staff to care for complex residents. And this is challenging. And we have nursing assistants also who are have has have more training to provide care for more complex residents. Okay. So we with all of these things that we are dealing with, how can we best pick up on clinical changes? And that's the key. That is the key, picking up on clinical changes to alert the health care team, the nurse practitioners if they are in our facilities, notifying the physicians, the medical director of some things that are happening so that we can detect things early. Now we do know there are times when resident clinical changes are unavoidable. Things happen. People do have chest pains, people do have stroke, things happen. But when we can pick up on some changes early, and that's really key, and that is really something you really want to enhance your education for your nursing assistants, your housekeepers, people who know the residents, to say, if something seems different, speak up. Okay, so that's a critical factor right there in some early detection. Okay?

Tracking ER Transfers With Dashboards

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So it's important that we are tracking data related to the incidence of emergency room transfers. And it's also important that we track on dashboards the importance of not only that, but hospital return, return to the hospital data. Because we want the interdisciplinary team, our boards, to have this information, to look at it and say, what's going on? Why do we have this? Why do we have this incidence of occurrence? Because that should stimulate the team to want to know why. Is something happening in our facilities? Is something going on in our resident population? Is it the types of residents that we're admitting to our facilities? It should really ask a lot of those why questions, okay? And lead to maybe A, more education might be required. I mean, it might need some processes, it could be some system changes are happening. So if you have a dashboard and you're tracking the data, it should lead to more investigation. So we know the CMS is already tracking that data. Each state has this data, the national, there's national reporting for ER emergency room tracking, as well as hospital data for short-stay resident populations in facilities. Because the CMS wants to know why you just admitted someone, why are they going back to the ER already? Why are they going to the hospital for admission? What's happening? Okay. They recognize sometimes people do go to the nursing facilities maybe too soon. So what's happening? It doesn't mean you did anything wrong, but what's happening? It just further stimulates some questions about why.

unknown 6:08

Okay?

SPEAKER_01 6:09

All right. Okay. So we do want to look at that information to hopefully lead us into a little more inquiry.

Advanced Care Planning And Family Choices

SPEAKER_01 6:17

So now I want to transition into the importance of advanced care planning. This is really important. We know this. So hopefully discussions have occurred, you know, back at the pre-hospital or at the hospital, where families have come together to talk with one another to say, you know, what are mom's, dad's wishes as far as advanced care planning, living wills, resuscitation status. What what are the plans? We know that doesn't always exist in families. They're not comfortable or just maybe they just didn't happen. Okay. So they get admitted to the nursing facility. These processes need to be uh looked at and discussed. We know it's it's not always easy. Social services needs to facilitate this discussion along with the provider and the nursing team to say, you know, what what are your plans? It's going to be really critical because this will be the time when the discussion occurs related to the emergency room transfer decision making, the rehospitalization transfer admission decision making. So that the this is a process that needs to occur and it needs to reoccur periodically. All right. We do know that we will have in times when people change their mind. We know that. I know that mom said, I don't want to go back to the emergency room, I want to stay here. But families, we know, will get frightened and say, I want dad sent anyways. So we need just to track. We need to keep track of this information to say, you know, what what's happening? You know, we seem to be having some variances here where maybe we need to look at our educational processes. Maybe we need to do some things differently with our education to help families to have a better understanding or or maybe some coping or some other kinds of resources. And don't forget, we do have other resources available in our industry. We have ombudsmen's programs that can help families and help facilities. And again, the physician's role is critical. Not just in talking about advanced care planning, but to emphasize that well, their role is critical to say, you know, we can care for your mom and dad, your brother, sister here in the facility, safely, effectively in the nursing facility. All right.

Readmission Trends And Diagnosis Clues

SPEAKER_01 8:55

So as far as looking at hospital readmission, you really do want to take some time to analyze trends. So people who do get admitted to the hospital for sometimes elective reasons or things happen, they're they're sent. You're certainly going to want to look at their codes, their primary code for admission, but look at their secondary codes too. What took them there? It might have been, let's see, they may have been admitted there for something like, oh, I don't know, delirium or something, but might find out that it was euroscepsis or whatever. So sometimes it's not always apparent when someone goes to the emergency room and then gets read then gets admitted. So what what are the diagnoses, the top diagnoses? Because that really does help us to get a sense of maybe we might be missing some things clinically on in our facilities. Helps sharpen our skills to detect, hopefully, to the extent that that can be done. Okay. You'll want to look at that because if you start noticing some trends with, it seems like we've had in the last several months, several residents admitted with UTIs or pneumonias, it appears as though we are having more residents with our quality measures spiking with UTIs. You want to pay attention to is there any correlation there?

unknown 10:24

Okay.

SPEAKER_01 10:25

So looking at some of that data to see if there are any correlations, and looking at how are we doing with our clinical changes, and looking at our tools that we have available to us to pick up on those. And some certainly some periodic staff education, re-education, and looking at some diagnostic indicators that might lead to some questions that we can ask the providers about.

CMS Research On Avoidable Hospitalizations

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So back in 2012, I was part of a CMS CMS initiative where I was working with a long-term care institute as a consultant, and they were involved in a project collecting some research information on reducing avoidable hospitalizations in nursing facility with nursing facility residents. And it was a f in five states. I was only involved in a couple of states, but what we were looking at is was there any benefit in having facility-based nurse practitioners or advanced practice RNs in those facilities to help facilitate their presence to avoid reducing rather avoidable hospitalizations just by their presence being there as a resource to staff? And so we were collecting data to find out if CMS's hypothesis, I guess, would be correct. So and also in addition to that, pardon me. In addition to that, we were looking at was the use of structured assessment tools helpful for staff to detect early clinical changes in collaboration with those nursing advanced practice nurses? So we looked at those initiatives to look at uh approaches to minimize both uh admissions to the hospital and transfers to the emergency room. And so you can read more about that if you'd like. But it was very good to be involved in looking at. I got to observe how staff really embraced the the learning and wanting to improve their processes and put systems in place to have some methodologies to keep their residents in their facilities. Okay.

Clinical Tools And Antibiotic Stewardship

SPEAKER_01 12:54

So how can you let me move on to leveraging clinical tools. So we do know that the CMS does track this data, and their expectation is that facilities are putting systems into place to improve their quality measures. All right. So there are so many clinical guidelines, best practices, there are tools out there to help facilities detect for changes to improve their clinical practices. Just take, for an example, the um the American Healthcare Association, they offer educational programming. For example, the clinical scenarios related to asymptomatic bacteria versus urinary tract infection. That's just one educational programming example. There are so many educational programming offerings out there to help staff. And in that example that I just mentioned, that focus is appropriate to look at antibiotic stewardship to prevent unnecessary transfers to the ER. We know our resident populations, as they age, they don't always want to drink water or drink fluid-rich food or consume fluid-rich foods. We know that. We know UTIs can occur in resident populations. And so we have to have diligence to avoid that at all costs. So in any case, let me wrap up by just simply saying early detection, best practices, involving the interdisciplinary team in monitoring care, to pick up on clinical changes, tracking and trending, to notice things, to watch for trends, and to look at the other resources that are out there for continued education, to educate families and residents about options that are available to keep residents in the facilities, looking at advanced care planning, all of that is so important to move facilities forward, to achieve the goals of keeping residents in facilities to the extent possible. And it's important when you have outliers, because you will, you will have outliers, to keep track of those and say, you know, we we expect we're going to have outliers, and we know that. But you'll be able to explain them, and that's what's important. And so you will have outliers, but you'll say, boy, but look at that. We we really have we have significantly uh reduced our avoidable emergency room transfers, and we've significantly reduced our avoidable admissions to hospitals, and that really benefits the residents in the in the long run.

Key Takeaways And How To Reach Us

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So thank you for listening, and I hope this was helpful. Thank you. Thank you for listening. Your time is appreciated. We hope you enjoyed this episode of Vital Compliance Insights and found this to be informative. Please feel free to reach out to Verity Consulting at VerityTeam.com if you'd like further assistance with your healthcare compliance needs. Stay tuned for the next episode.