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20:10
J Nurs Care Qual Vol. 30, No. 4, pp. 380–384 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Hospital Readmission Rates Following Skills Training for Nurses Employed in Long-term Care Facilities Susan L. Hovey, MS, RN; MyoungJin Kim, PhD; Mary J. Dyck, PhD, RN, LNHA Reducing hospital readmissions is a priority for health care providers and affects Medicare reimbursement. The purpose of this study was to determine whether there is a significant difference in readmission rates from long-term care facilities to hospitals with the implementation of a training program for long-term care nurses. The main findings revealed that the training did not significantly affect hospital readmissions; however, the organization saw a significant decrease in hospital readmissions after 24 months of data collection. Key words: hospital readmission, long-term care, Medicare, staff education
T
HE AFFORDABLE Care Act of 2010 established a readmission reduction policy with the intent of improving quality of care and reducing costs for Medicare beneficiaries.1 The reduction program reduces payments to hospitals with excess allcause readmissions within 30 days for patients admitted with acute myocardial infarction, heart failure (HF), and pneumonia.1 All-cause readmission means that the patient does not
Author Affiliation: Mennonite College of Nursing at Illinois State University, Normal. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Mary J. Dyck, PhD, RN, LNHA, Mennonite College of Nursing at Illinois State University, Campus Box 5815, Normal, IL 61790 ([email protected]). Accepted for publication: December 26, 2014 Published ahead of print: February 2, 2015 DOI: 10.1097/NCQ.0000000000000117
have to be readmitted for the same condition or related conditions to be included. An innovative strategy by a senior care corporation to reduce readmissions from long-term care (LTC) facilities to hospitals was evaluated in this study. BACKGROUND The Hospital Readmission Reduction Program requires the Centers for Medicare & Medicaid Services to reduce payments to hospitals with excess readmissions beginning October 1, 2012.1 Penalties to hospitals with excess readmission for patients discharged with acute myocardial infarction, HF, or pneumonia include a 1% reduction of total Medicare billings in 2013, 2% reduction of total Medicare billings in 2014, and 3% reduction of total Medicare billings in 2015.2 Because of the number of hospital readmissions throughout the United States, readmissions to hospitals are costly to the health care system. Studies by Jencks et al3 and Mor et al4 verify why the health care industry needs to examine the number and cost of readmissions.
380
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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Hospital Readmission Rates After Skills Training of LTC Nurses Approximately 19.6% of 11 855 702 Medicare beneficiaries who had been discharged from the hospital were readmitted within 30 days between 2003 and 2004 and cost Medicare $17.4 billion.3 Of all Medicare hospitalized discharges, 18% receive care at LTC facilities, with these patients having a high rate of early unplanned readmissions.2,5 In 2006, of 1.79 million hospitalizations from LTC facilities, approximately 23.5% resulted in readmission costing Medicare $4.34 billion.4 Given that hospitals and acute care settings are experiencing reimbursement reductions for Medicare beneficiaries, they are exploring ways to reduce readmissions. With the high incidence of readmissions from LTC facilities, hospitals have focused attention on reducing readmissions from facilities that provide post–acute care. Several initiatives have been evaluated to address the problem of hospital readmissions from LTC facilities including partnering with post– acute care providers, implementing quality improvement programs, increasing physician presence, improving communication and medication reconciliation, and focusing on care of populations with chronic conditions in the LTC setting, especially residents with HF.5−12 However, to date, no studies have been found that measure the significance of a skills training course designed for nurses working in LTC facilities to improve clinical skills. The purpose of this study was to determine whether there is a significant difference in readmission rates from LTC facilities to hospitals with the implementation of a 1-day skills laboratory training course for nurses employed by a senior care corporation. The study examined the readmission rates at 3, 6, and 9 months after training. CONCEPTUAL FRAMEWORK The Donabedian quality model guided the conceptual framework for this study. According to Donabedian,13 information about the quality of care can be drawn from 3 as-
381
sessment categories. These categories include structure, process, and outcome. Donabedian13 defines 3 assessment categories in the quality model. Structure is the setting in which care takes place. Structure includes adequacy of facilities and equipment, human resources, and organizational features. Donabedian13 describes process as a means to an end. It represents all of the interactions patients have with health care providers including those for diagnosis, treatment, and preventive care. Not only does process include the types of care delivered but also the manner in which the care is delivered. Outcome is the effect that the structure and process have on the health status of the patient. Donabedian13 views outcomes as a way of validating quality. According to Donabedian,13 the primary goal is to improve health care by improving the health status of patients or populations. The outcome in this study is the number of readmissions following the introduction of skills training for nurses. METHODS Sample A senior care corporation in Illinois collected and de-identified the data. The senior care corporation owns and operates 32 LTC facilities. A convenience sample of these facilities was used for data collection (see Supplemental Digital Content, Table, available at: http://links.lww.com/JNCQ/A164). Preintervention data were collected on 29 facilities and postintervention data were collected on 32 facilities. Monthly staff from each facility collected data on hospital admissions and allcause readmissions within 30 days. Admission data included admissions and readmissions for new residents admitted to the facilities and by current residents. Before analyzing the data, the senior care corporation and the university signed a data use agreement. The university institutional review board determined that the study was exempt from review because it did not meet the definition for human subjects’ research.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
382
JNCQ-D-14-00111
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JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2015
Procedure The senior care corporation implemented a 1-day skills laboratory training course in September 2011 to improve skills of nurses employed at its facilities. The training was revised in January 2012. A master’s prepared nurse designed and delivered the training. The training consisted of an hour lecture on HF and an hour lecture on chronic obstructive pulmonary disease. Following the lectures, nurses spent 45 minutes practicing assessment skills with a simulation manikin. Using the simulation manikins, nurses practiced and discussed acute changes in patient conditions for 3 hours. For 1.5 hours, nurses used patient scenarios to practice communication skills with situation background assessment recommendation (SBAR) forms and simulated calls to physicians. SBAR is a standardized way of communicating and promotes patient safety by setting a shared set of expectations for interdisciplinary communications. By February 2013, 12 of the 32 facilities had 50% or more of their nurses attend and complete the training. Because the 1-day skills laboratory training was not mandatory, attendance by facility varied. To assess effectiveness of the intervention, the decision was made to compare facilities with a 50% or greater attendance with facilities with less than a 50% attendance. Administrative staff employed by the senior care corporation gathered the data collected on admissions and readmissions by each facility monthly over 24 months and entered the raw data into a Microsoft Excel spreadsheet. For purposes of this study, a readmission was defined as a return to the hospital within 30 days after discharge for any reason. The administrative staff also collected and entered into the Microsoft Excel spreadsheet the number of nurses employed at each facility, number of nurses who completed the skills laboratory training, and dates that the training was completed. The hospital readmission rates were collected at 3, 6, and 9 months after training to compare the rates between LTC facilities (n = 32) where 50% of nurses completed train-
ing (n = 12) and facilities whose nurses did not complete training (n = 20). The hospital readmission rates for LTC facilities (n = 29) were also measured and compared between December 2011 and December 2013. Data collection and the skills training course was launched in December 2011. Preintervention readmission rates were collected in December 2011 before the launch. By December 2013, data collection and skills training had been occurring for 24 months. A convenience sample of 29 facilities was used for this analysis because the senior care corporation had only collected data on 29 facilities in 2011. The 3 facilities not included with initial data collection in 2011 were omitted for this analysis. Analysis The data were received on a Microsoft Excel spreadsheet and were imported into IBM SPSS 20.0 (IBM Corp, Armonk, New York) in which all data were analyzed. The data were assessed for outliers. The Mann-Whitney U test was used to compare 30-day hospital readmission rates between the 2 groups of LTC facilities. A Wilcoxon signed-rank test was used to compare hospital readmission rates for LTC facilities between December 2011 and December 2013. All statistical significances were reported at P < .01. RESULTS The 2 analyses had different results. LTC facilities that had 50% or more of their staff members attend the skills laboratory were not significantly different in hospital readmission rates from the LTC facilities that did not have their staff attend the skills laboratory at 3, 6, and 9 months after training (Table). However, when comparing hospital readmission rates preintervention with postintervention, readmission rates were significantly lower postintervention (z = −3.85, P < .001). Results showed that hospital readmission rates in December 2013 (M = 1.28, SD = 1.10, median = 1.28) were significantly lower than in December 2011 (M = 3.48, SD = 2.68, median = 3.48).
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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August 4, 2015
20:10
Hospital Readmission Rates After Skills Training of LTC Nurses Table. Comparing Hospital Readmissions M (SD) Median 3 mo Training ≥50%a Training ≤50%b 6 mo Training ≥50% Training ≤50% 9 mo Training ≥50% Training ≤50% an bn
1.8 (1.7)
1.00
1.4 (1.9)
0.00
1.8 (1.5)
2.00
1.6 (2.5)
1.00
2.2 (1.4)
1.50
1.9 (1.8)
1.00
z
P
− 1.22 .255
− 1.01 .346
− 1.04 .346
= 12. = 20.
DISCUSSION The initiative taken by the senior care corporation to support the development and implementation of a 1-day skills training laboratory to reduce hospital readmissions was unique. The results of the study found a significant decrease in hospital readmissions when comparing pre- with postintervention. However, a significant difference could not be found when comparing LTC facilities that had the majority of their nursing staff complete skills training with facilities that did not. The reasons for this difference need to be explored further. No significant difference could be found in hospital readmission rates when comparing LTC facilities that had at least half of their staff complete skills training with those facilities that did not when measured at 3 different points in time. Because there is a risk with low sample sizes of not finding significance when in fact there is, it is important to consider the results of the medians. When analyzing the medians during the same period, it was found that readmission rates were lower for LTC
383
facilities that did not have 50% or more nurses trained in the skills laboratory. The question that remains is why the skills training did not result in a significant difference in readmission rates when comparing facilities with a higher attendance with facilities with a lower attendance at the skills training and why the median readmission rates during the same period were lower for facilities with a lower attendance at the skills training laboratory. It is plausible that the LTC facilities that had half or more of their nurses complete the training had a higher mean rank of hospital readmissions because the nurses may have become sensitive to and developed a heightened awareness on identifying changes in patient condition. After attending the skills training, the nurses’ assessment skills, use of the SBAR, and communication skills with interdisciplinary providers including physicians improved. By enhancing these skills, the nurses were better at identifying changes and had more confidence in notifying the physician if warranted. It can be posited that the skills training was effective but did not have the planned effect of significantly reducing hospital readmission rates. Reevaluation and revision of the skills laboratory may be necessary to achieve the intended outcome. What this study showed is that readmission rates significantly declined over the 24 months that administration was collecting data and providing skills training with an emphasis on decreasing readmission rates. Several factors may account for this decrease. It is possible that the attention of the administrative staff from the senior care corporation on readmissions influenced the actions of the nurses at LTC facilities and alerted nurses to the importance of reducing readmissions. In addition, monthly collection of readmission data may have encouraged nurses to discontinue unnecessary readmissions. It can be theorized, as described in the Donabedian quality model, that because a change in process resulted in a significant decrease in readmission rates over 24 months that the quality of care in the LTC facilities
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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JNCQ-D-14-00111
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August 4, 2015
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JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2015
improved. According to Gerhardt et al,14 hospital readmission rates are inversely related to quality of care. When the senior care corporation made a change in process, in this case, the introduction of a nursing skills laboratory and ongoing attention to hospital readmission rates, there was a change in outcome, which was a decrease in hospital readmission rates. Limitations This study has several limitations. This study had a small sample size. Only 1 senior care corporation may not be representative of LTC facilities in general. The senior care corporation collected the data, so the researchers relied on the accuracy of the staff’s data collection techniques. Nursing staff in LTC facilities are constantly changing, so the data may have not accurately captured nurses who actually trained. In addition, the study did not measure training of nurses outside of the 1-day skills laboratory training course. Future research Currently, research in this area is limited, so the need is great. The study should be
replicated using a larger sample size and controlling for some of the extraneous variables. Enlarging the study parameters to include how many days following discharge residents are generally readmitted and the reasons for readmission following discharge would add to the study. CONCLUSION This study compared hospital readmission rates from LTC facilities following the initiation of a 1-day skills training course. The study found that after 2 years of data collection and training of nurses, hospital readmission rates significantly decreased but readmission rates in facilities where 50% or more of their nurses completed the training were not significantly different from facilities that did not. Hospital readmission rates are receiving interest from health care providers and politicians. Recent changes in Medicare reimbursement for hospital readmission rates have resulted in acute care and LTC providers exploring ways to reduce readmission rates.
REFERENCES 1. Centers for Medicare & Medicaid Services. http:// www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/AcuteInpatientPPS/Readmissions-ReductionProgram.html. Updated 2014. Accessed June 21, 2014. 2. Zigmond J. Avoiding the penalty box. Mod Healthc. 2012;42(5):38-39. 3. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-forservice program. N Engl J Med. 2009;360(14):14181428. 4. Mor V, Intrator O, Feng Z, Grabowski DC. The revolving door of rehospitalization from skilled nursing facilities. Health Aff. 2010;29(1):57-64. 5. Berkowitz RE, Jones RN, Rieder R, et al. Improving disposition outcomes for patients in a geriatric skilled nursing facility. J Am Geriatr Soc. 2011;59(6):11301136. 6. Aston G. Long-term care: your new priority. Hosp Health Netw. 2011;85(4):30-32. 7. Butcher L. Hospitals strengthen bonds with postacute providers: goals: boost quality, cut readmissions, prepare for value-based pay (strategy). Hosp Health Netw. 2013;1:34.
8. Boxer RS, Dolansky MA, Frantz MA, Prosser R, Hitch JA, Pi˜ na IL. The bridge project: improving heart failure care in skilled nursing facilities. J Am Med Dir Assoc. 2012;13(1):83.e1-83.e7. 9. Hutt E, Frederickson E, Ecord M, Kramer AM. Associations among processes and outcomes of care for Medicare nursing home residents with acute heart failure. J Am Med Dir Assoc. 2003;4(4):195-199. 10. Jacobs B. Reducing heart failure hospital readmissions from skilled nursing facilities. Prof Case Manage. 2011;16(1):18-26. 11. Blank LJ, Benyo EM, Glover JU. Bridging the gap in transitional care: a closer look at medication reconciliation. Geriatr Nurs. 2012;33(5):401-409. 12. Cortes TA, Wexler S, Fitzpatrick JJ. The transition of elderly patients between hospitals and nursing homes: improving nurse-to-nurse communication. J Gerontol Nurs. 2004;30(6):10. 13. Donabedian A. Evaluating the quality of medical care. Milbank Q. 2005;83(4):691-729. 14. Gerhardt G, Yemane A, Hickman P, Oelschlaeger A, Rollins E, Brennan N. Medicare readmission rates showed meaningful decline in 2012. Medicare Medicaid Res Rev. 2013;3(2):E1-E11.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JNCQ-D-14-00111
August 4, 2015
20:10
J Nurs Care Qual Vol. 30, No. 4, pp. 380–384 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Hospital Readmission Rates Following Skills Training for Nurses Employed in Long-term Care Facilities Susan L. Hovey, MS, RN; MyoungJin Kim, PhD; Mary J. Dyck, PhD, RN, LNHA Reducing hospital readmissions is a priority for health care providers and affects Medicare reimbursement. The purpose of this study was to determine whether there is a significant difference in readmission rates from long-term care facilities to hospitals with the implementation of a training program for long-term care nurses. The main findings revealed that the training did not significantly affect hospital readmissions; however, the organization saw a significant decrease in hospital readmissions after 24 months of data collection. Key words: hospital readmission, long-term care, Medicare, staff education
T
HE AFFORDABLE Care Act of 2010 established a readmission reduction policy with the intent of improving quality of care and reducing costs for Medicare beneficiaries.1 The reduction program reduces payments to hospitals with excess allcause readmissions within 30 days for patients admitted with acute myocardial infarction, heart failure (HF), and pneumonia.1 All-cause readmission means that the patient does not
Author Affiliation: Mennonite College of Nursing at Illinois State University, Normal. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Mary J. Dyck, PhD, RN, LNHA, Mennonite College of Nursing at Illinois State University, Campus Box 5815, Normal, IL 61790 ([email protected]). Accepted for publication: December 26, 2014 Published ahead of print: February 2, 2015 DOI: 10.1097/NCQ.0000000000000117
have to be readmitted for the same condition or related conditions to be included. An innovative strategy by a senior care corporation to reduce readmissions from long-term care (LTC) facilities to hospitals was evaluated in this study. BACKGROUND The Hospital Readmission Reduction Program requires the Centers for Medicare & Medicaid Services to reduce payments to hospitals with excess readmissions beginning October 1, 2012.1 Penalties to hospitals with excess readmission for patients discharged with acute myocardial infarction, HF, or pneumonia include a 1% reduction of total Medicare billings in 2013, 2% reduction of total Medicare billings in 2014, and 3% reduction of total Medicare billings in 2015.2 Because of the number of hospital readmissions throughout the United States, readmissions to hospitals are costly to the health care system. Studies by Jencks et al3 and Mor et al4 verify why the health care industry needs to examine the number and cost of readmissions.
380
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-14-00111
August 4, 2015
20:10
Hospital Readmission Rates After Skills Training of LTC Nurses Approximately 19.6% of 11 855 702 Medicare beneficiaries who had been discharged from the hospital were readmitted within 30 days between 2003 and 2004 and cost Medicare $17.4 billion.3 Of all Medicare hospitalized discharges, 18% receive care at LTC facilities, with these patients having a high rate of early unplanned readmissions.2,5 In 2006, of 1.79 million hospitalizations from LTC facilities, approximately 23.5% resulted in readmission costing Medicare $4.34 billion.4 Given that hospitals and acute care settings are experiencing reimbursement reductions for Medicare beneficiaries, they are exploring ways to reduce readmissions. With the high incidence of readmissions from LTC facilities, hospitals have focused attention on reducing readmissions from facilities that provide post–acute care. Several initiatives have been evaluated to address the problem of hospital readmissions from LTC facilities including partnering with post– acute care providers, implementing quality improvement programs, increasing physician presence, improving communication and medication reconciliation, and focusing on care of populations with chronic conditions in the LTC setting, especially residents with HF.5−12 However, to date, no studies have been found that measure the significance of a skills training course designed for nurses working in LTC facilities to improve clinical skills. The purpose of this study was to determine whether there is a significant difference in readmission rates from LTC facilities to hospitals with the implementation of a 1-day skills laboratory training course for nurses employed by a senior care corporation. The study examined the readmission rates at 3, 6, and 9 months after training. CONCEPTUAL FRAMEWORK The Donabedian quality model guided the conceptual framework for this study. According to Donabedian,13 information about the quality of care can be drawn from 3 as-
381
sessment categories. These categories include structure, process, and outcome. Donabedian13 defines 3 assessment categories in the quality model. Structure is the setting in which care takes place. Structure includes adequacy of facilities and equipment, human resources, and organizational features. Donabedian13 describes process as a means to an end. It represents all of the interactions patients have with health care providers including those for diagnosis, treatment, and preventive care. Not only does process include the types of care delivered but also the manner in which the care is delivered. Outcome is the effect that the structure and process have on the health status of the patient. Donabedian13 views outcomes as a way of validating quality. According to Donabedian,13 the primary goal is to improve health care by improving the health status of patients or populations. The outcome in this study is the number of readmissions following the introduction of skills training for nurses. METHODS Sample A senior care corporation in Illinois collected and de-identified the data. The senior care corporation owns and operates 32 LTC facilities. A convenience sample of these facilities was used for data collection (see Supplemental Digital Content, Table, available at: http://links.lww.com/JNCQ/A164). Preintervention data were collected on 29 facilities and postintervention data were collected on 32 facilities. Monthly staff from each facility collected data on hospital admissions and allcause readmissions within 30 days. Admission data included admissions and readmissions for new residents admitted to the facilities and by current residents. Before analyzing the data, the senior care corporation and the university signed a data use agreement. The university institutional review board determined that the study was exempt from review because it did not meet the definition for human subjects’ research.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
382
JNCQ-D-14-00111
August 4, 2015
20:10
JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2015
Procedure The senior care corporation implemented a 1-day skills laboratory training course in September 2011 to improve skills of nurses employed at its facilities. The training was revised in January 2012. A master’s prepared nurse designed and delivered the training. The training consisted of an hour lecture on HF and an hour lecture on chronic obstructive pulmonary disease. Following the lectures, nurses spent 45 minutes practicing assessment skills with a simulation manikin. Using the simulation manikins, nurses practiced and discussed acute changes in patient conditions for 3 hours. For 1.5 hours, nurses used patient scenarios to practice communication skills with situation background assessment recommendation (SBAR) forms and simulated calls to physicians. SBAR is a standardized way of communicating and promotes patient safety by setting a shared set of expectations for interdisciplinary communications. By February 2013, 12 of the 32 facilities had 50% or more of their nurses attend and complete the training. Because the 1-day skills laboratory training was not mandatory, attendance by facility varied. To assess effectiveness of the intervention, the decision was made to compare facilities with a 50% or greater attendance with facilities with less than a 50% attendance. Administrative staff employed by the senior care corporation gathered the data collected on admissions and readmissions by each facility monthly over 24 months and entered the raw data into a Microsoft Excel spreadsheet. For purposes of this study, a readmission was defined as a return to the hospital within 30 days after discharge for any reason. The administrative staff also collected and entered into the Microsoft Excel spreadsheet the number of nurses employed at each facility, number of nurses who completed the skills laboratory training, and dates that the training was completed. The hospital readmission rates were collected at 3, 6, and 9 months after training to compare the rates between LTC facilities (n = 32) where 50% of nurses completed train-
ing (n = 12) and facilities whose nurses did not complete training (n = 20). The hospital readmission rates for LTC facilities (n = 29) were also measured and compared between December 2011 and December 2013. Data collection and the skills training course was launched in December 2011. Preintervention readmission rates were collected in December 2011 before the launch. By December 2013, data collection and skills training had been occurring for 24 months. A convenience sample of 29 facilities was used for this analysis because the senior care corporation had only collected data on 29 facilities in 2011. The 3 facilities not included with initial data collection in 2011 were omitted for this analysis. Analysis The data were received on a Microsoft Excel spreadsheet and were imported into IBM SPSS 20.0 (IBM Corp, Armonk, New York) in which all data were analyzed. The data were assessed for outliers. The Mann-Whitney U test was used to compare 30-day hospital readmission rates between the 2 groups of LTC facilities. A Wilcoxon signed-rank test was used to compare hospital readmission rates for LTC facilities between December 2011 and December 2013. All statistical significances were reported at P < .01. RESULTS The 2 analyses had different results. LTC facilities that had 50% or more of their staff members attend the skills laboratory were not significantly different in hospital readmission rates from the LTC facilities that did not have their staff attend the skills laboratory at 3, 6, and 9 months after training (Table). However, when comparing hospital readmission rates preintervention with postintervention, readmission rates were significantly lower postintervention (z = −3.85, P < .001). Results showed that hospital readmission rates in December 2013 (M = 1.28, SD = 1.10, median = 1.28) were significantly lower than in December 2011 (M = 3.48, SD = 2.68, median = 3.48).
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-14-00111
August 4, 2015
20:10
Hospital Readmission Rates After Skills Training of LTC Nurses Table. Comparing Hospital Readmissions M (SD) Median 3 mo Training ≥50%a Training ≤50%b 6 mo Training ≥50% Training ≤50% 9 mo Training ≥50% Training ≤50% an bn
1.8 (1.7)
1.00
1.4 (1.9)
0.00
1.8 (1.5)
2.00
1.6 (2.5)
1.00
2.2 (1.4)
1.50
1.9 (1.8)
1.00
z
P
− 1.22 .255
− 1.01 .346
− 1.04 .346
= 12. = 20.
DISCUSSION The initiative taken by the senior care corporation to support the development and implementation of a 1-day skills training laboratory to reduce hospital readmissions was unique. The results of the study found a significant decrease in hospital readmissions when comparing pre- with postintervention. However, a significant difference could not be found when comparing LTC facilities that had the majority of their nursing staff complete skills training with facilities that did not. The reasons for this difference need to be explored further. No significant difference could be found in hospital readmission rates when comparing LTC facilities that had at least half of their staff complete skills training with those facilities that did not when measured at 3 different points in time. Because there is a risk with low sample sizes of not finding significance when in fact there is, it is important to consider the results of the medians. When analyzing the medians during the same period, it was found that readmission rates were lower for LTC
383
facilities that did not have 50% or more nurses trained in the skills laboratory. The question that remains is why the skills training did not result in a significant difference in readmission rates when comparing facilities with a higher attendance with facilities with a lower attendance at the skills training and why the median readmission rates during the same period were lower for facilities with a lower attendance at the skills training laboratory. It is plausible that the LTC facilities that had half or more of their nurses complete the training had a higher mean rank of hospital readmissions because the nurses may have become sensitive to and developed a heightened awareness on identifying changes in patient condition. After attending the skills training, the nurses’ assessment skills, use of the SBAR, and communication skills with interdisciplinary providers including physicians improved. By enhancing these skills, the nurses were better at identifying changes and had more confidence in notifying the physician if warranted. It can be posited that the skills training was effective but did not have the planned effect of significantly reducing hospital readmission rates. Reevaluation and revision of the skills laboratory may be necessary to achieve the intended outcome. What this study showed is that readmission rates significantly declined over the 24 months that administration was collecting data and providing skills training with an emphasis on decreasing readmission rates. Several factors may account for this decrease. It is possible that the attention of the administrative staff from the senior care corporation on readmissions influenced the actions of the nurses at LTC facilities and alerted nurses to the importance of reducing readmissions. In addition, monthly collection of readmission data may have encouraged nurses to discontinue unnecessary readmissions. It can be theorized, as described in the Donabedian quality model, that because a change in process resulted in a significant decrease in readmission rates over 24 months that the quality of care in the LTC facilities
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-14-00111
384
August 4, 2015
20:10
JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2015
improved. According to Gerhardt et al,14 hospital readmission rates are inversely related to quality of care. When the senior care corporation made a change in process, in this case, the introduction of a nursing skills laboratory and ongoing attention to hospital readmission rates, there was a change in outcome, which was a decrease in hospital readmission rates. Limitations This study has several limitations. This study had a small sample size. Only 1 senior care corporation may not be representative of LTC facilities in general. The senior care corporation collected the data, so the researchers relied on the accuracy of the staff’s data collection techniques. Nursing staff in LTC facilities are constantly changing, so the data may have not accurately captured nurses who actually trained. In addition, the study did not measure training of nurses outside of the 1-day skills laboratory training course. Future research Currently, research in this area is limited, so the need is great. The study should be
replicated using a larger sample size and controlling for some of the extraneous variables. Enlarging the study parameters to include how many days following discharge residents are generally readmitted and the reasons for readmission following discharge would add to the study. CONCLUSION This study compared hospital readmission rates from LTC facilities following the initiation of a 1-day skills training course. The study found that after 2 years of data collection and training of nurses, hospital readmission rates significantly decreased but readmission rates in facilities where 50% or more of their nurses completed the training were not significantly different from facilities that did not. Hospital readmission rates are receiving interest from health care providers and politicians. Recent changes in Medicare reimbursement for hospital readmission rates have resulted in acute care and LTC providers exploring ways to reduce readmission rates.
REFERENCES 1. Centers for Medicare & Medicaid Services. http:// www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/AcuteInpatientPPS/Readmissions-ReductionProgram.html. Updated 2014. Accessed June 21, 2014. 2. Zigmond J. Avoiding the penalty box. Mod Healthc. 2012;42(5):38-39. 3. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-forservice program. N Engl J Med. 2009;360(14):14181428. 4. Mor V, Intrator O, Feng Z, Grabowski DC. The revolving door of rehospitalization from skilled nursing facilities. Health Aff. 2010;29(1):57-64. 5. Berkowitz RE, Jones RN, Rieder R, et al. Improving disposition outcomes for patients in a geriatric skilled nursing facility. J Am Geriatr Soc. 2011;59(6):11301136. 6. Aston G. Long-term care: your new priority. Hosp Health Netw. 2011;85(4):30-32. 7. Butcher L. Hospitals strengthen bonds with postacute providers: goals: boost quality, cut readmissions, prepare for value-based pay (strategy). Hosp Health Netw. 2013;1:34.
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