Avoiding End of Life Transfers from Nursing Home to Hospital

It’s encouraging to see the California HealthCare Foundation tackle the issue of unnecessary nursing home to hospital transfers that occur in the last weeks of life. The PREPARED project, comprising collaboration between hospitals and nursing homes, showed some success in reducing unneeded hospitalizations, improving quality of life and improving family member satisfaction. The factors that added to the success of the program were fairly predictable. They included:

• Strong and ongoing administrative leadership and support
• The presence of advance care planning champions
• Involvement of doctors
• A culture of quality improvement
• The availability of educational opportunities for families and residents

The last factor is noteworthy, because it suggests that better informed people lean toward avoiding unneeded hospitalizations. They don’t see it as rationing or a death panel. Key factors detracting from success were perhaps more enlightening:

• Some of the participating facilities were undergoing surveys by the California Department of Health Services during the timeframe of the PREPARED project. As the report notes, all elective activities including quality improvement usually get dropped during these surveys, which can last for months
• Nursing homes have financial incentives to transfer. They get paid for three days to hold the bed for the resident’s return, and they get enhanced payments triggered by the hospital stay
• Many nursing home staff are ignorant of end-of-life issues in general and lack expertise on the concept and details of advance care planning
• Lack of knowledge on pain and symptom management
• Not enough time in the day for staff to take advantage of resources provided by this project

These detractors are fairly discouraging. It’s definitely worthwhile for families of prospective residents to try to get a handle on some of these issues in advance if at all hospitals. I really liked it that the researchers clearly identified three ways that hospitals lose out financially from unneeded end-of-life admissions. These are the most likely findings to encourage change:

• At least in California, where Kaiser Permanente has a big presence, there are integrated systems where total costs go up if a patient is transferred to an acute setting. To the extent Accountable Care Organizations (ACOs) take global payments, this incentive will spread
• Even in a fee-for-service environment, these end-of-life nursing home patients can be unattractive to hospitals. That’s because admissions that end in a patient death are typically unprofitable. Costs are high and not fully recoverable
• Hospitals will begin to be penalized for preventable re-admissions under the Affordable Care Act. Many nursing home residents suffer from conditions such as heart failure and pneumonia that are subject to re-admissions penalties. Avoiding nursing home to hospital transfers at end of life also cuts readmissions

I’d really like to believe that these financial incentives for hospitals are robust but I’m not totally convinced they’re as real as the authors seem to think.