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.
