02 July 2013

Elderly and Rehospitalization

This is a real problem and applying all sorts of names to it will not make it change. Why hospitals consistently think they can just push patients off on skilled nursing facilities (SNF) without proper care instructions is a mystery. This attitude is about to start causing them penalties and then they will begin severe rationing of health care on the elderly. This in turn will cause legal problems and calls for large settlements.

Hospitals are short of staff because they have been cutting costs by reducing staff instead of creating healthcare efficiencies. Hospitals in turn are blaming SNF for the readmissions when in fact; it is the lack of poor care coordination and discharge planning by the hospitals. Maybe the authors of this article are correct in calling these readmissions a “bounce back” to the hospital. This is being documented more and more for Medicare patients and it is estimated that one of four patients are being re-hospitalized within 30 days of discharge to a skilled nursing facility.

Yes, I could lay some blame on the SNF, but the hospitals must shoulder most of the blame for their lack of communications with the SNF. Occasionally a SNF will not exist near the hospital and the nursing homes do not have qualified medical staff available and do not follow through with the few instructions they do receive. These are the sad situations.

Medicare should also shoulder some of the blame for their mixed up payment rules which puts burdens on the patient, SNF, and the hospitals.

Then we must look at the patients themselves. A good portion of the patients in SNFs have limited functional capabilities and are often dependent on skilled nursing care. The following are patients' characteristics:

#1. The average age is close to 80 years,

#2. One-third of the patients are affected by cognitive diseases,

#3. 50% of SNF residents have at least three to six limitations in their basic activities of daily living,

#4. One-half of the residents are being managed for five or more chronic diseases - many that are considered terminal.

When looking at the above list, we need to be concerned about the type of care these people are receiving. I must wonder if they are receiving aggressive and unnecessary care or if they need palliative care instead. If they are truly in the last stages of life, then why are the physician, hospitals, and SNFs playing the aggressive roulette to milk money from Medicare and Medicaid when palliative care may be the best treatment? Probably because palliative care reimbursements are so low from Medicare.

A recent report published by the Institute of Medicine shows that this is happening more in some regions of the country than other regions. Unfortunately, there is no definitive answer about why this is occurring. We do know that advance care planning is inadequate. The inability of providers to correctly and actively counsel patients and their families in a dialog about the patients' prognosis and their goals of care should be a major concern. Yet this often does not happen.

Palliative care is not considered by the providers and too often, the patients are just told to have “do not resuscitate” (DNR) directives and “do-not-hospitalize” (DNH) directives on file and no further discussion about them. The patients and their families are then left wondering how these will be acted upon and when. There have been too many examples where these have been ignored, sidestepped, or aggressively adhered to when a discussion should have taken place. Therefore, is it any wonder many patients are concerned about having these directives on file when they are aggressively adhered to by uncaring doctors? A local example was a 45-year old that was having heart problems and his doctor refused to do anything because of a DNR in his file. Resuscitation was not the issue and an operation to repair a valve problem would have meant quality of life for possibly many years. It is no wonder when he passed in 24 days that the doctor had no DNR defense and the jury returned a hefty judgment for the family.

Is it any wonder that patients become concerned when doctors request these at younger and younger ages? Patients are becoming smarter and making them unenforceable below certain ages without family consent. Yet, even here, a doctor choose to ignore this and claimed that the DNH allowed him to avoid liability even if the patient was under the age of 50 and had operable cancer. The jury declared a huge financial award to the patient's family.

Then on the good side, there is a doctor that has this discussion when a patient passes a fiftieth birthday. The doctor is very open about all possibilities and family involvement is something that he feels should be considered and encouraged. This doctor discusses everything from acute care, palliative care, and hospice care to minor care. This doctor correctly feels advance care planning is often times neglected at nursing facilities and can lead to distressing end-of-life experiences for the patients and their families.

During the last few months of life, comfort measures may be more appropriate than aggressive life sustaining interventions at the hospital ICU. Under current Medicare rules, Medicare reimbursements provide a financial incentive to nursing homes to hospitalize Medicaid nursing home residents, who are receiving long-term care. In addition, since Medicare reimburses nursing homes a higher rate for skilled services, patients who transition to the hospice care benefit are not considered “favorable” patients and must pay for room and board out of pocket or through enrollment in Medicaid, for which many patients are not eligible.

Therefore, once in either a hospital or skilled nursing facility, patients can be caught in the profit game and are rotated endlessly between the two facilities and receive aggressive and expensive care procedures which may not be in the best interest or care of the patient.

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