Rounding program reduces hospital readmission risk
By JULIE MINDA
Insurers — most notably Medicare — are influencing how and where care is delivered. With a growing focus on value-based purchasing and risk sharing, payers are incenting providers to move hospital patients into skilled nursing facilities for recuperative and rehabilitative treatments and to do so without increasing the risk a patient will relapse.
But unlike hospitals, nursing facilities generally don't have physician specialists in-house to frequently assess patients' progress and alter care plans dynamically. To meet the challenge of caring for more acute medical issues in a subacute setting, Bon Secours Maria Manor Nursing & Rehabilitation Care Center in St. Petersburg, Fla., has recruited physician specialists to treat patients at the skilled nursing facility. It did so by making the case that the specialists' involvement on-site would improve patient care outcomes and reduce avoidable hospital readmissions.
Dr. Mihaela Soran, a geriatrician who is medical director of Maria Manor and treats patients there, said, "In skilled nursing you're caring for the most complex and frail population, so having physicians actively involved in managing (patients with) conditions with the highest rates of rehospitalization, I think is a very good situation.
"The patients are happy, they're being seen by specialists — it's a great way to go forward," she said. Participating physicians also benefit because they're able to get more involved in their patients' care, including by getting more valuable information from nursing staff during in-person conversations.
Communications loop
The 274-bed Maria Manor offers skilled nursing, rehabilitation and long-term care nursing. It has a dedicated 32-bed unit for short-term rehab patients. The facility is part of Bon Secours St. Petersburg Health System, which operates a 102-unit assisted living facility adjacent to Maria Manor as well as home care services around Tampa Bay. Maria Manor's short-term rehabilitation residents have an average length of stay of about 30 days; and most of its short-term rehab patients and long-term care residents are dually eligible for Medicare and Medicaid.
Currently four private practice physician specialists round at least monthly at Maria Manor. In addition to Soran, they include a pulmonologist, a cardiologist and an orthopedist. An effort is under way to recruit an endocrinologist and a neurologist. The specialists can treat any Maria Manor resident in need of specialty care.
Maria Manor has been hosting regular meetings between the rounding specialists and the residents' primary care doctors, to encourage relationship-building; and the specialists also keep the residents' doctors informed by making notes on the residents' medical records.
Slow build
Karen Reich, chief executive of Bon Secours St. Petersburg, explained that the trend toward hospitals discharging patients earlier than in the past, and with more acute needs, has been building over several decades. It began around 1982 when Medicare started paying hospitals a set amount based on a patient's diagnosis. To bring the cost of providing care in line with the reimbursement for each particular diagnosis, hospitals had to manage the level of services they provide, and work to reduce patients' lengths of stay. Patients who were too frail or sick to be discharged home were transferred to step-down care facilities including skilled nursing facilities.
The Affordable Care Act added a new check and balance to the treatment plan: Government payers now penalize hospitals financially when a specified ratio of their patients are readmitted to the hospital within 30 days of their discharge for certain conditions thought to be preventable. (The ratio varies by hospital; the Centers for Medicare & Medicaid Services determines the ratio based on each hospital's discharge data.)
Value added
Reich said the physician panel and rounding effort is making Maria Manor an attractive choice for local hospitals discharging patients too sick or frail to return home immediately.
"We are trying to position ourselves as the best choice for receiving these hospitals' patients because we are dedicated to providing the best care delivery and continuously advancing our ability to treat people in place to avoid readmission," Reich said. This helps hospitals to manage risk, she said.
Stephanie Slankard, a member of the administrative team at Bon Secours St. Petersburg, said it is very common for nursing facility patients with lung, heart, brain or endocrine conditions or following joint replacement surgery to require posthospital follow-up care from specialists. In the past, these recovering patients normally would wait until they were discharged from Maria Manor before returning to the specialist. When it was necessary to transport a skilled nursing patient to a specialist's office, the trip could be arduous for patients who are frail and elderly, Slankard said, and it could disrupt their rehabilitation schedule, added Reich.
Navigating a new system
Reich said it took her several years to identify and recruit providers to Maria Manor's panel of physician specialists. "It took a long time to find individuals who understood the rationale and who could give the time" to round in the nursing home, she said.
Dr. Jose Luciano practices pulmonology as part of Coastal Pulmonology and Critical Care. He rounds at Maria Manor every two weeks, visiting patients identified as requiring follow-up by nurses acting in collaboration with the patients' primary care physicians. He treats people with chronic obstructive pulmonary disease, other lung diseases and pneumonia. He bills Medicare directly for his visits to Maria Manor patients and is reimbursed at a nursing home visit rate, which is about the same amount as he is reimbursed when he provides care in his office. He said that on rare occasion he will ask that a patient be transported to another location for tests that require non-portable equipment.
This is his first experience delivering care in a nursing home. Luciano said he's able to assess patients and intervene before conditions deteriorate to the point of requiring hospital care.
Skill building
In addition to treating patients, the specialists teach Maria Manor's frontline nursing staff how to better assess and care for residents who are fresh out of the hospital and still weak or very ill.
Slankard said the nursing staff — particularly, the patients' designated care nurses — "learn through their interactions with the physicians how to watch for subtle changes in patients' conditions."
The specialists also present in-service trainings for nursing staff — both registered and licensed practical nurses. For instance, Luciano has educated Maria Manor nursing staff on chronic obstructive pulmonary disease, coughing, breathing therapy and asthma.
Reich said that the education program is part of a broader effort in which Maria Manor also provides online, in-house and external education opportunities to its nursing staff so that their competencies will be similar to those of a nurse in a medical-surgical environment in a hospital.
Bon Secours' Slankard said patients and their family members appreciate the new approach. "Because when (families) come here from the hospital, they are often in a state of crisis, trying to make decisions ... When mom breaks a hip, it's great for them to have the providers here, face-to-face, reassuring them and developing a care plan with them.
"Being able to have physicians involved in that process is a tremendous value-added service and comfort that we can offer," she said.
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