A practical partnership
Date: June 15, 2012
Once a week, Jonathan Zenilman, chief of infectious disease at Johns Hopkins Bayview Medical Center, and Karen Daniels, a nurse practitioner who runs the Outpatient Parenteral Antibiotic Therapy program, spend an afternoon at a nursing home in Glen Burnie, far from their normal surroundings.
It is part of a new collaboration designed to spot problems at long-term care facilities after patients discharged from hospitals arrive needing intravenous antibiotic treatments.
The two review microbiology data, lab results, antibiotic doses and the patients’ response to therapy and also provide consultations and feedback to the nursing home staff.
“We noticed the vast majority of missed appointments at the antibiotic clinic were from nursing home discharges,” Zenilman says. “And since appointments are key to making sure discharged patients are getting the right care, we decided to come to them.”
For example, Daniels reviewed the chart of one elderly resident at North Arundel Health and Rehabilitation Center, a division of Sava Senior Care, who had asymptomatic bacteriuria and was about to have an invasive IV line inserted for a seven-day antibiotic treatment. The team’s recommendation was that the line and treatment were unnecessary.
Zenilman says Sava is interested in extending this program to its other facilities as a way to reduce the need for hospital readmissions.
The Bayview-Sava collaborative is one of several projects with skilled nursing facilities undertaken as part of a Hopkins initiative to meet the Centers for Medicare and Medicaid Services’ mandate to lower readmissions rates. CMS estimates costs associated with preventable readmissions exceed $17 billion a year nationwide.
Carol Sylvester, Bayview’s senior director of care management, leads the Hopkins task force working on collaborations with skilled nursing facilities. “Inside the hospital, we’ve been quick to see that patients sent to nursing homes for rehabilitation and recovery return to hospitals at rates far higher than discharging them to their homes,” she says.
Compounding the problem, she adds, is a lack of understanding by hospital staff about the workings of long-term care facilities. There are far fewer physicians and registered nurses than in a hospital, “yet the patients coming to them from here are frail, and their cases are complex.”
Sylvester adds that in today’s world, shorter hospital stays mean “we discharge patients to nursing homes when they are stable, not when they are completely well. There’s a belief that someone at the nursing home will be monitoring the situation as closely as in the hospital, which is not necessarily the case.”
Neither hospitals nor long-term care facilities “do a good enough job getting transfer information to each other. We want to improve handoffs and communication.”
The task force also wants to implement the best medical practices at nursing facilities, centering on the most common patient ailments—heart failure, chronic obstructive pulmonary disease, antibiotic therapy, anti-coagulation therapy, delirium, debility and treatment of pain.
The group has developed an evaluation sheet that nursing home staff can fill out when a patient is readmitted to Bayview or The Johns Hopkins Hospital “so we can understand the factors contributing to patients being readmitted,” Sylvester says. “Did we communicate well enough? Did our patients get the appropriate and best medical attention?”
Another initiative is spearheaded by Michele Bellantoni, associate professor and clinical director of the Division of Geriatric Medicine and Gerontology, which is partnering with the five skilled nursing facilities that have the highest number of patients discharged from Bayview and Hopkins Hospital.
These facilities, plus the Johns Hopkins Care Center at Bayview, where Bellantoni is the medical director, have jointly applied to the CMS Innovations Center for a grant to improve outcomes after transfers and discharges.
“We’ve identified some of the reasons why patients’ conditions worsen in nursing settings after coming from the Care Center,” she says, “Now we want to share things we have found out that work,” such as the center’s anti-coagulant protocol and diabetes management following an acute hospital stay. Bellantoni believes the Care Center has developed an effective system of communication among medical providers and nurses that also can be employed in a skilled nursing setting to identify and address changes in a patient’s medical condition before instability develops.
Part of the grant application, she notes, involves better sharing of patient data, “which is breaking down a big barrier.” Eventually she sees this involving electronic communications on admissions and discharges and rapid two-way communication when questions arise.
Bellantoni also is putting together a continuing medical education program on this issue for the November meeting of the state’s nursing home medical directors. “We need to jointly develop expertise on how to best handle these transfers.”
AHEAD OF THE GAME
Within the Hopkins hospital system, Suburban Hospital in Bethesda is viewed as the acknowledged leader in collaborative work with nursing homes. “They are very sensitive to the issues,” says Carol Sylvester, who leads the Hopkins task force working to curb hospital readmissions from nursing home. .
Medicare patients make up 60 percent of Suburban’s inpatient days, and a high percentage come from nursing homes, according to Norma Bent, director of outcomes management at Suburban.
Bob Rothstein, the hospital’s vice president for medical affairs, says that over the last few years the hospital has ramped up its connection with the 500-bed Hebrew Home of Greater Washington.
In April, Suburban and Hebrew Home put on the symposium “Transitions in Care: Perspectives for Clinicians and Caregivers,” which drew more than 200 people.
A multidisciplinary group from Suburban and Hebrew Home meets regularly at both facilities to improve processes, according to Barbara Jacobs, senior director of nursing at Suburban. “We’re seeing a big improvement in our communication and feel we are enhancing the patient experience,” she says.
In addition, Hebrew Home educators and Suburban nursing educators have met to share information on training and resources. The Hebrew Home educators observed some nursing training sessions and a nursing council meeting at Suburban to take that information back to their facility.
Both Suburban and Hebrew Home have improved their discharge forms and included more relevant patient data and treatment needs. They are working to enhance electronic access to patients’ medical information from either site. Suburban is informing Hebrew Home ahead of time when a patient transfer requires special treatment. Suburban transition guide nurses immediately communicate with the nursing home if one of their patients is readmitted to the hospital.
These steps, taken over the past year, are producing what Jacobs calls “a dramatic decrease” in hospital readmissions.
Last winter, the nursing home’s readmissions to Suburban consistently exceeded 20 percent. Since collaborative steps commenced, readmissions have dropped this spring to less than 10 percent.
Because of this success, Suburban is extending these collaborative efforts to other area nursing homes.