River View Post Acute Care Center in New Jersey continually searches for ways to improve our residents' lives. The facility's leaders observed admission histories, in-house treatment options and readmission to hospital for causalities and rationales.

Our staff concurs with the Academy Health Incorporated power point presentation online on "Reducing Hospital Readmissions" that, for most patients who leave the hospital, the last thing they want is to return anytime too soon. Yet, many Medicare patients discharged from an inpatient stay find themselves back in the hospital within 30 days.

River View wanted to assess whether there are missed opportunities or areas of compromised care that results in readmissions to the hospitals within 30 days of discharge. In studying this outcome, River View took several variables to compare before and post-interventional measures that would impact on quality care and healthier River View residents. For this small study, data was collected pre-interventions for two months and then post interventions for two months in order to compare hospital readmission rates. Data continues to be collected.

Historical Background
With the introduction of Diagnosis Related Groupings in the hospitals since the early 80s patients' hospital stays became shorter, and patients were transferred to skilled nursing facilities earlier with more comorbidities and high acuities. Often the higher acuity patients cannot go home as the family or caregiver is not able to manage the person's needs, have insufficient resources or lacks knowledge of healthcare standards.

In 2007, Centers for Medicare & Medicaid began initiating DRG prospective payment systems that not only include diagnosis but severity, prognosis, risk of mortality, ease of treatment, cost of resources and the need for interventions. In 2010, the CMS integrated quality outcome and payment links so that hospitals that have nosocomial adverse events (such as a hospital acquired blood stream infection or pressure ulcer) are not paid for outcomes that were avoidable. Hospitals realized that less adverse events and higher reimbursement occurs if the stay is short and disease or condition is efficiently and effectively treated. Thus the patient is faced with early discharge home or short-term/ post acute nursing home admissions. With earlier discharges, the skilled nursing homes returned unstable or frail residents to hospitals.

About Us
River View Post Acute Care Center has 180 dual Medicare/ Medicaid certified beds for use. It has 60 dedicated to sub-acute/ post-acute care. In 2009, the nursing staffing ratios were typically completed by census tracking. Care concerns seemed higher than other units. Attending physicians were on-call day and night. Most admissions arrived during the evening shift when attending physicians were not present. Physician orders from the hospitals were transcribed by unit supervisors after a physician was called to confirm. If a resident required acute care treatments such as intravenous antibiotics, wound care assessments, intravenous fluid regimens and similar modalities, the resident was sent to the hospital for assessment, treatment and possible admission. This was not seen as poor care but as hospital/ acute care. The transferring residents were seen as acute and unstable in that their vital signs may have been abnormal, laboratory results low or high, symptoms of infections or cardio-pulmonary compromised.

New payment systems (Resource Utilization Grouping/ RUGS), definable quality improvement outcome indicators (quality indicators), staffing guides (Case Mix Indexes/ CMI) and a transitional annual state survey system were introduced. A tool that has been updated several times called the minimum data set (MDS) sets thresholds for surveyors, measures and monitors these categories of each resident in the skilled nursing home. The acuity of the present residents is greater than a year ago.

With higher acuity from hospitals, the department of health and senior services re-examined staffing ratios on surveys, utilized quality indicators for survey guidance and sampling during site visits and revised necessary regulations. River View assessed present staff and re-educated or trained them on new skills and technology that would support residents' longer stays, acutely treating conditions in efforts to prevent hospital readmissions. Resident acuities are monitored by nursing monthly and showed that for the same two time periods (January through July 2010 and 2011) that residents continue to trend upwards toward more clinically complex. In 2011, River View admitted more residents with acuities such as tracheotomy, dialysis, oxygen/ respiratory needs and gastrotomy tubes.

What We Did
As hospitals were evolving, the skilled nursing homes standards were changing simultaneously. River View evaluated concerns from attending physicians, residents, family members and staff to search for solutions. These are just a few of the changes made that impacted the quality of care and services offered.

  • Hiring of case managers (nurses) who link hospital patients to prompt but appropriate admissions.
  • Gathering sufficient clinical information from hospital referrals for appropriate admissions.
  • Exploration of advance directives prior to skilled nursing home admission.
  • Pre-admission assessment regarding medication management concerns.
  • Pre-admission requests for specialty items (e.g. beds, mattresses, oxygen, or other supportive devices)
  • Intravenous therapy certification was required for specific nursing staff.
  • Speed of intravenous medications (e.g. antibiotics) was being trended from our pharmacy.
  • Laboratory results turnaround times were monitored for physician responses.
  • Re-training registered nurses using the Interact tools (Situational Background Assessment Recommendations/ SBAR) regarding what to report to attending physician.
  • Hiring additional registered nurses for the sub-acute unit.
  • Hiring a board certified geriatric nurse practitioner with staggered hours to match approximate times of the arrival of new admissions.
  • Board certified geriatric nurse practitioner expertise utilized to assess all admissions for smooth transition to reconcile hospital care to skilled nursing facility plans of care.
  • Board certified geriatric nurse practitioner assesses each resident to treat internally and trends whether hospital admission was avoidable or unavoidable.
  • Attending physicians follow their residents care progress from the hospital to the skilled nursing facility to confirm continuity in resident health plans.
  • River View Post Acute Care Center shares pertinent information with the medical directors (Dr. R. Rizzo, Dr. P. Krisa and Dr. M. Wahba) and referring hospitals.
  • Utilizing River View Post Acute medical experts for in-house consultations for specialties such as pulmonary, cardiac, physiatrist (pain management) and wound management.
Findings Reviewed
River View Post Acute Care Center's readmission rate declined by 39% between June 14, 2010 to August 14,  2011. The nurse practitioner saw most residents within minutes to an hour of arrival (depending upon the number of admissions during the evening tour). The two major causes of hospital readmissions were found to be sepsis or fever/ infectious process.

Assessments from the Interact tool revealed that most hospital readmissions resulted from a new symptom. The nurse practitioner was present during the off-tour and has actively treated residents' acute conditions thus reducing hospital admissions. Registered nurses utilize the assessment tool from Interact to more proactively assess and report to the nurse practitioner and the medical team to treat residents onsite rather than sending residents to hospital.

Conclusions
When our medical directors and nurse practitioner analyzed the data they concluded that despite increased acuities more residents remained at River View for treatments for acute conditions. The nurse practitioner evaluated all readmissions to the hospital for the 2011 timeframe and found that 87% were unavoidable, 10% were possibly avoidable (due to resident noncompliance and family requests) and 3% were avoidable (resident request with leg edema). During this time frame, 73% of hospital readmissions were within 30-days of admission to River View. When analyzed none of the 30-day hospital readmissions were unavoidable. Resident mortality levels were less after the interventions were implemented in 2011. Payment source for readmissions in 2010 was about 13% Medicare A while in 2011 6% for Medicare A. River View Post Acute Care Center findings confirmed the benefits of interventions to the residents' health, cost effectiveness and quality care and services offered.

Acknowledgements
River View Post Acute Care Center appreciates the support and recommendations of our home office staff (A. Eisenreich, President and Linda Dooley, Vice President of Operations).

River View Post Acute Care Center wishes to recognize the Interventions to Reduce Acute Care Readmissions/ INTERACT quality improvement program for their tools and recommendations that made River View Post Acute Care Center deliver better and more efficient care and services while improving their quality of life for our residents.

River View Post Acute Care Center is grateful to our geriatric nurse practitioner (Julya Rempel) who has experience as a nurse practitioner who collaborates with multiple physicians but is also wound care certified and an experienced registered nurse in New Jersey and New York. She has utilized evidence- based practices from INTERACT to prevent readmissions to the acute care setting thus improving the quality of life for many of our residents.

Wendy Trimboli, LNHA, MA, RN, CPHQ, CIC, is the administrator at River View Post Acute Care Center. Data was provided by Julya Remple, GNP-BC, for this post.