LWW/JNCQ
JNCQ-D-13-00176
February 3, 2014
23:17
J Nurs Care Qual Vol. 29, No. 2, pp. 103–109 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Innovations in Quality Improvement in Long-Term Care The purpose of this column is to discuss innovations and quality improvement advancements across the various long-term care settings. This column is coordinated by Marilyn J. Rantz, PhD, RN, FAAN, NHA, [email protected].
Hospital to Nursing Home Transition Challenges Perceptions of Nursing Home Staff Lori Popejoy, PhD, APRN, GCNS-BC; Colleen Galambos, PhD, ACSW, LCSW, LCSW-C; Amy Vogelsmeier, PhD, RN
P
ROJECTED health care trends indicate that skilled nursing facilities will have an increased role in delivering health care services in the United States. More than 1.4 million residents were living in US nursing homes in 2011.1 Estimates indicate that 42% of older Americans will spend at least 1 year
Author Affiliation: Sinclair School of Nursing, (Drs Popejoy and Vogelsmeier) and School of Social Work (Dr Galambos), University of Missouri, Columbia. The authors acknowledge John A. Hartford Foundation’s National Hartford Centers of Gerontological Nursing Excellence Award Program. Drs. Popejoy and Vogelsmeier are National Hartford Centers of Gerontological Nursing Excellence Claire M. Fagin Fellows. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Lori Popejoy, PhD, APRN, GCNS-BC, S420 Sinclair School of Nursing, University of Missouri, Columbia, MO 65212 ([email protected]). DOI: 10.1097/NCQ.0000000000000051
in a nursing facility in their lifetime.2 It is also well documented that care transitions present challenges to both the discharging and receiving facilities.3 These challenges are further exacerbated by shorter lengths of stay and increased health acuity.4 A study about challenges to hospital discharge planning in Missouri revealed that hospitals have difficulty in finding nursing homes that will accept patients with complex health care needs such as dialysis, chemotherapy, radiation therapy, wound vacuums, and mental health needs.3 The study, however, did not identify why it was difficult to find placement for patients who had these conditions. To overcome this gap in knowledge, a survey was developed to learn from the nursing facility perspective the challenges faced in transitioning residents to skilled nursing facilities from hospitals. This article reports on the findings from that survey and describes the nursing home staff’s perspective of challenges with hospital to nursing home transitions. RESEARCH DESIGN AND SPECIFIC AIM This descriptive study used a cross-sectional Web-based survey targeted to health care 103
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
104
JNCQ-D-13-00176
February 3, 2014
23:17
JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2014
teams in nursing homes involved with admitting residents from hospitals to nursing homes. The specific aim was to describe the types of problems encountered by nursing homes when admitting residents from hospitals. Data collection procedure and sample After obtaining institutional review board approval, survey respondents were contacted via the Quality Improvement Program of Missouri (QIPMO) nurses’ list serve network. The QIPMO program offers expert nurse consultation to nursing homes to support quality improvement and facilitate systems change in nearly 500 nursing facilities.5 An e-mail invitation and link to the electronic survey was sent to each QIPMO nurse who in turn posted it to his or her list serve of nursing home contacts for the QIPMO program. The survey invitation was sent to contacts from 474 nursing homes in Missouri. Respondents were asked to complete 1 survey per home and to describe which team members contributed to survey completion. Instrument The original hospital survey3 was adapted for nursing homes by a multidisciplinary team composed of 2 doctoral prepared nurse researchers who are advanced practice registered nurses board certified in gerontology, and a doctoral prepared social worker. In addition, a review of the literature about problems with discharges from the hospital was undertaken, and the survey was revised to reflect these challenges described in the literature. Content validity of the survey was established in 2 ways. First, nurses from QIPMO reviewed the survey and offered suggestions for improving the questions for clarity, anchors, and flow. In addition, they were asked whether there were any issues that were not addressed in the survey. Second, the primary investigator (LLP) then met with 2 QIPMOsponsored support groups that represented 6 different nursing homes and were composed of minimum data set coordinators, administra-
tors, and directors of nursing to review each question and anchor to identify questions that were not relevant or were unclear. There were no substantive changes suggested, but instructions and slight changes to the wording of the questions were made on the basis of their recommendations. The survey comprised 81 Likert-type and short answer questions about problems with resident transfers from hospitals to nursing homes. First, respondents were asked to rate how willing they are to accept residents with certain types of problems or needs. Scores ranged from 1 (very willing) to 5 (never willing) to accept. Second, nursing homes were asked to rate the frequency with which they encounter problems when admitting residents from the hospital. Scores for that scale ranged from 1 (very often) to 5 (never) encountered the problem. At the end of each scale, there were opportunities to provide additional information. Finally, there were opportunities to respond to questions about useful strategies for communication with hospital personnel and about what can be done to improve communication between hospitals and nursing homes. Analysis For each question in the survey, the results were summarized using the Genmod procedure in SAS V9 (SAS Institute Inc, Cary, North Carolina). A Tukey-Karmer adjustment for multiple comparisons among different conditions was used. Differences were considered statistically significant if the adjusted P value was less than .05. A content analysis of the short answer questions was done. Answers were sorted by question, like responses were counted for each question, and finally answers were categorized into general types of issues or problems by the principal investigator. Coinvestigators reviewed the short answers and the initial coding categories and then the group discussed revisions and made adjustments on the basis of group consensus. Items and problems were grouped into broader categories.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00176
February 3, 2014
23:17
Hospital to Nursing Home Transition Challenges RESULTS Sample Nursing homes were asked to complete a single survey per site using the perspective of multiple team members. There were 475 survey links distributed; 178 (38%) surveys were returned from all 7 geographic regions of Missouri. Job categories of respondents included licensed nurses, directors of nursing, minimum data set coordinators, physicians, social workers/social work designees, case managers, managers/administrators, and physical or occupational therapists. Nearly 70% (n = 117) of the homes were for-profit, and the remainder (n = 52) were not-for-profit. Just under 60% (n = 105) of homes were of bed size between 61 and 120 beds, nearly 30% (n = 52) were of more than 120 beds, and the remainder (n = 19) were of 60 beds or lesser. Nearly 80% (n = 139) of respondents reported that their facility was 10 miles or less from the nearest hospital, 16% (n = 28) of respondents reported being within 25 miles from a hospital, and only 6% (n = 10) reported being 50 miles or less. One facility was 75 miles from the nearest hospital. Willingness to accept transfers There was variation in the degree of willingness of nursing homes to accept hospital residents with a variety of medical conditions or needs. Residents with treatments that nursing homes were not willing or never willing to accept included those who require a ventilator (P < .05), total parenteral nutrition (P < .05), and use of a sitter (P < .05) (Table 1). Medical conditions and patients with other needs that nursing homes were less willing to accept at transfer included behavior management problems, wound vacuum, tracheostomy, infection requiring isolation, chemotherapy, radiation therapy, mental illness, morbid obesity, and developmental disability (Table 1). Sixty-eight respondents provided additional information about other medical conditions or issues that affected their willingness to accept residents from hospitals. Mentioned
105
most frequently as influencing their willingness to accept patients were high costs of care (n = 17). Nursing homes also noted that they were unlikely to admit residents who have the potential for behavior that placed other residents or the organization at risk for problems, such as elopement potential (n = 10), aggressive or combative behaviors (n = 9), sex offenders or known criminal history (n = 5), substance abuse (n = 4), and suicide risk (n = 4). Organizing transfers Nursing homes were asked to rate how often they encountered specific problems during hospital transitions. The Supplemental Digital Content Table, available at http://links. lww.com/JNCQ/A61, describes the problems in rank order of occurrence. The issues viewed as most problematic by nursing homes included lack of communication between the hospital physician and the accepting physician, advance health care directives not being sent, patients’ routine medication being changed during the hospitalization, and resident’s condition worse than expected on arrival. Problems reported as less problematic were mental illness, infection, new injuries not reported, and no verbal report given. There were no statistically significant differences in reported problems. Sixty-three respondents made additional comments about problems encountered at the time of transfer. Nearly 30 respondents indicated that there were often problems with physician orders including contradictory or missing orders, omitted prescriptions for opioid medications, and order changes made immediately prior to hospital discharge. Twenty respondents reported that they received too much information from the hospital that was hard to understand, not timely, not readable, or for the wrong patient. Another 20 respondents specifically identified problems related to late or poorly timed admissions, for example, meal times or late in the day, transportation issues, and expensive procedures not done prior to hospital discharge or ordered after nursing home admission.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00176
106
February 3, 2014
23:17
JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2014
Table 1. Medical Conditions and Willingness of Nursing Homes to Accept Hospital Patients, Ranked From Least to Most Willing Medical Condition/Treatment Ventilator Total parenteral nutrition Requires a sitter Behavior management problem Tracheostomy Morbid obesity Infection requiring isolation Chemotherapy Mental illness Developmental disability Radiation therapy Wound vacuum Hemodialysis Transportation to and from medical appointments Fall risk Intravenous therapy Pressure ulcer Dementia Dressing change Requires physical and/or occupational therapy Diabetes a1
n
Mean Scorea
SD
Rank
168 168 167 171 172 168 171 170 171 171 168 172 172 168
4.82b 3.89b 3.63b 2.78 2.74 2.52 2.32 2.27 2.22 2.19 2.19 2.17 1.79 1.68
0.5 1.5 1.06 0.94 1.37 1.20 1.16 1.30 1.08 1.20 1.24 1.31 1.08 0.94
1 2 3 4 5 5 7 8 9 10 11 12 13 14
169 172 172 172 173 173
1.46 1.42 1.33 1.23 1.18 1.07
0.70 0.89 0.56 0.49 0.41 0.26
15 16 17 18 19 20
173
1.05
0.22
21
= very willing, 2 = willing, 3 = somewhat willing, 4 = not willing, 5 = never. significant difference from other conditions/treatments.
b Statistically
Nursing homes were divided in their willingness to admit residents on the weekends, with more than half (n = 98) responding that they would very often or often accept weekend admissions. Although nearly 90% of nursing homes reported that they were unlikely to request a delay in transfer, 125 respondents commented about specific reasons they would request a delay such as for a new or unstable medical condition (n = 24). It is worth noting that a number of nursing home respondents identified challenges related to human or material resources as a reason for transfer delay including lack of availability of equipment or supplies (n = 49), inability to secure medications including narcotic prescriptions (n = 27), late in the day or weekend referrals
(n = 12), and nursing home staff and physician availability (n = 11). Medications and treatment orders Respondents were asked to rate on a scale of 1 to 5 how often they had difficulty obtaining medications within 24 hours after hospital discharge. Lower scores indicate more problems. Of the 147 responses, the only statistically significant problem was not having a signed controlled substance prescription available (mean: 2.6, SD: 1.2, P < .05). Other items were transfer orders requiring clarification (mean: 2.9, SD: 1.0), pharmacy services not available at night (mean: 3.5, SD: 1.3) or on the weekend (mean: 3.7, SD: 1.17), needed medications not available
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00176
February 3, 2014
23:17
Hospital to Nursing Home Transition Challenges from dispensing pharmacy (mean: 3.6, SD: 0.86), and common medications not available in emergency kit (mean: 3.6, SD: 0.94). Of the 68 who commented on medications that were difficult to obtain within 24 hours, 37 identified narcotics, followed by antibiotics (n = 11). Next, respondents were asked to describe how much time on average they spend in activities related to callbacks and clarifying orders. Of 153 respondents, 20% spend less than 30 minutes making callbacks and clarifying orders, about one-third (n = 55) spend 30 minutes to 1 hour, nearly another third (n = 45) spend 1 to 2 hours, and slightly more than 13% (n = 21) spend 2 to 3 hours. In terms of the average time spent reconciling medications, just below 10% (n = 11) spend less than 30 minutes, nearly half (n = 74) spend 30 minutes to 1 hour, about a third (n = 53) spent 1 to 2 hours, and the remainder (n = 12) spend more than 2 hours. Finally, on the topic of medications, respondents described activities that take the most time when reconciling medications. The majority of the 112 respondents who responded to this question cited having to overcome challenges when encountering unclear orders (n = 62) and having to “decipher” or “figure out” (n = 31) orders that are incomplete, illegible, or confusing. They clarified orders through activities such as reviewing transfer documents and communicating with others (n = 31) including contacting the physician and waiting for return calls (n = 38). Communication Respondents were asked to identify strategies to improve communication with hospitals. Nearly half (n = 38) indicated that it would be helpful to talk to a single knowledgeable person about the resident. Respondents expressed frustration about the lack of consistency in hospital nursing staff and encountering staff who did not know the residents and yet were giving reports about them. Nursing home staff expressed frustration when they called the hospital with questions about a resident, and no one with knowledge of the in-
107
dividual was available to speak with them. Strategies to overcome these issues include a name and callback number for contact, speaking with a single identified person such as a social worker, use of standardized reports such as INTERACT (Interventions to Reduce Acute Care Transfers), or meeting residents face-toface in the hospital. DISCUSSION It is well documented that at the time of transition from the hospital, many patients require extensive rehabilitation and recuperation. As with all settings, nursing homes vary in their ability to manage residents recently discharged from the hospital. It was clear from this survey that there are common problems with hospital transition to the nursing home that stress the human, material, and financial capacity of the nursing home. Perhaps the most significant issue is that nursing homes have limited registered nurse resources to manage residents with complex needs.6 Yet, many residents come to nursing homes from hospitals with significant ongoing care needs for problems such as renal failure requiring hemodialysis, complex wounds, infections, postsurgical care and rehabilitation, and chronic disease management. These complex patients need equipment, treatments, and medications that are not readily available in many nursing homes, requiring that hospitals carefully communicate patients’ needs so that residents’ ongoing care needs can be accommodated. Patients’ needs may be better met if hospitals and nursing homes move toward managing the common problems that affect residents at the time of transition. For instance, it is important for hospitals to know what type of care is available in nursing homes so that services may be continued without interruption at the time of transition between hospital and nursing home. Nursing homes expressed a reluctance to accept patients with behavioral problems and will not accept patients who require individual attention such as those needing a sitter. In a previous study, it was noted that patients
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00176
108
February 3, 2014
23:17
JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2014
Table 2. Process Recommendations for Transitional Improvement Hospital Communicate needed equipment in time for nursing homes to obtain it prior to transfer Communicate drugs or treatment that may require preauthorization well in advance of potential discharge Send narcotic prescriptions with resident
Institute provider-to-provider communication prior to discharge Discharge early in the day so that there is time for communication with transferring staff Identify residents’ problem behaviors including history, duration, and potential triggers to nursing homes
with mental health care needs were difficult for hospitals to place.3 Our research team surmised that the reluctance to accept those patients is because of the nursing home staff’s concerns about behavior, a lack of training and expertise about behavioral health, and the risk that problem behaviors pose for residents’ safety. The findings from this study support the assumption that it is residents’ behavior that in part makes nursing home admission problematic. Nursing homes are willing to consider accepting residents with a variety of behavioral issues ranging from the potential for elopement; combative, aggressive, or sexual aggressive behavior; substance abuse; and risk for suicide. Nursing homes may not be the appropriate place to care for people with extreme behavior problems, yet there are few postacute alternatives.6 Hospitals and nursing homes must work together to arrive at workable, safe solutions to these problems. Another major problem that places residents at risk for interrupted care or treatment is the access to medications by nursing homes. Narcotic prescriptions were particularly problematic because of the need for a signed nar-
Nursing Home Analyze nursing home capacity to care for residents with specific health care conditions Communicate to hospitals what drugs or treatments require authorizations Verify that narcotic prescriptions have been written and identify plan for obtaining the prescription if missing Identify provider-to-provider plan of communication with nursing home medical director or admitting physician Request transfer early in the day. If not possible, request name and phone number of after-hours provider contacts Identify whether behaviors can be successfully managed by identifying critical features of the behavior such as history, duration, and triggers
cotic prescription to obtain these medications from the pharmacy. When these signed prescriptions do not accompany residents to the nursing home, there is no practical way for the nursing home to obtain these medications, which may result in interrupted pain management. Many nursing homes do not have ready access to pharmacy services 24 hours a day.7 Preauthorization of medication is an emerging problem. Hospitals need to alert nursing homes about medications that are unusual or expensive, so plans for obtaining these medications can be made several days prior to the resident’s hospital discharge. In reality, medication orders that are unclear or require follow-up create barriers to the nursing home’s ability to provide safe uninterrupted care.8 An impediment to ongoing care is the lack of consistent medical providers across settings.9 The use of primary care physicians who cross all settings is becoming increasing rare.10 It is challenging for a nursing home to call back to a discharging hospital and get orders clarified; the physician who initiated the order may be gone, as is the nurse who had knowledge of the resident. To
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00176
February 3, 2014
23:17
Hospital to Nursing Home Transition Challenges overcome this problem, nursing home staff recommended obtaining the name and number of a contact person to call if there was a problem. They also identified social workers as a good contact, providing nursing homes with a single person who was knowledgeable about the resident and hospital stay. Improving hospital to nursing home provider-toprovider communication is vital. In general, communication with hospitals was problematic. The nursing homes reported that patients are often transitioned late in the day or on Friday afternoons. The nurse giving report was frequently not the person who had cared for the patient during the day, and if clarification was needed, the nurse was unable to answer questions about the resident. Table 2 outlines some protocol recommendations on the basis of the responses received from respondents in this study. Programs such as INTERACT have tools available to streamline and improve information exchanged during transition.11
109
CONCLUSION To solve problems with transfers from hospitals to nursing homes, it is important to understand the challenges faced by nursing homes that accept hospital patients for admission. Nursing homes are willing to accept challenging residents from hospitals provided they are given adequate information about equipment, medications, and behavioral needs, so that the correct resources can be arranged and put into place prior to patients’ transition. It is vital that plans for communication after the transition be in place for nursing homes to have access to staff or providers who can clarify orders. Process recommendations are provided to highlight the changes that are needed to improve transitions from hospitals to nursing homes. Given the increase in residents’ acuity and need for nursing home care, it is time to address the issues identified in this article.
REFERENCES 1. Centers for Medicare & Medicaid Services. Nursing home data compendium, 2012 edition. http:// www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/downloads/ nursinghomedatacompendium_508.pdf. Accessed October 11, 2013. 2. Ness J, Ahmed A, Aronow WS. Demographics and payment characteristics of nursing home residents in the United States: a 23 year trend. J Gerontol A Bio Sci Med Sci. 2004;59(11):1213-1217. 3. Popejoy LL, Galambos C, Moylan K, Madsen R. Challenges of hospital discharge for rural and urban older adults. Clin Nurs Res. 2012;21(4):431-449. 4. Toles M, Young HM, Ouslander J. Improving care transitions in nursing homes. J Am Soc Aging. 2013;36(4):78-85. 5. Rantz MJ, Cheshire D, Flesner M, et al. Helping nursing home “at risk” for quality problems: a statewide evaluation. Geriatr Nurs. 2009;30(4):238-249. 6. Seblega BK, Zhang NJ, Unruh LY, Breen GM, Paek SC, Wan TH. Changes in nursing home staff staffing
7.
8.
9.
10.
11.
levels, 1997-2007. Med Care Res Rev. 2010;67(2): 232-246. Vogelsmeier A, Scott-Cawiezell J, Zellmer D. Barriers to safe medication administration in the nursing home. J Gerontol Nurs. 2007;33(4):5-12. Vogelsmeier A, Scott-Cawiezell J, Pepper G. Medication reconciliation in nursing homes: thematic differences between RN and LPN staff. J Gerontol Nurs. 2011;37(12):56-63. Boockvar KS, Burack OR. Organizational relationships between nursing homes and hospitals and quality of care during hospital-nursing home patient transfers. J Am Geriatr Soc. 2007;55(7):1078-1084. Bodenheimer T. Coordinating care—a perilous journey through the health care system. New Engl J Med. 2008;358(10):1064-1071. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project. J Am Geriatr Soc. 2011;59(4):745-753.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JNCQ-D-13-00176
February 3, 2014
23:17
J Nurs Care Qual Vol. 29, No. 2, pp. 103–109 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Innovations in Quality Improvement in Long-Term Care The purpose of this column is to discuss innovations and quality improvement advancements across the various long-term care settings. This column is coordinated by Marilyn J. Rantz, PhD, RN, FAAN, NHA, [email protected].
Hospital to Nursing Home Transition Challenges Perceptions of Nursing Home Staff Lori Popejoy, PhD, APRN, GCNS-BC; Colleen Galambos, PhD, ACSW, LCSW, LCSW-C; Amy Vogelsmeier, PhD, RN
P
ROJECTED health care trends indicate that skilled nursing facilities will have an increased role in delivering health care services in the United States. More than 1.4 million residents were living in US nursing homes in 2011.1 Estimates indicate that 42% of older Americans will spend at least 1 year
Author Affiliation: Sinclair School of Nursing, (Drs Popejoy and Vogelsmeier) and School of Social Work (Dr Galambos), University of Missouri, Columbia. The authors acknowledge John A. Hartford Foundation’s National Hartford Centers of Gerontological Nursing Excellence Award Program. Drs. Popejoy and Vogelsmeier are National Hartford Centers of Gerontological Nursing Excellence Claire M. Fagin Fellows. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Lori Popejoy, PhD, APRN, GCNS-BC, S420 Sinclair School of Nursing, University of Missouri, Columbia, MO 65212 ([email protected]). DOI: 10.1097/NCQ.0000000000000051
in a nursing facility in their lifetime.2 It is also well documented that care transitions present challenges to both the discharging and receiving facilities.3 These challenges are further exacerbated by shorter lengths of stay and increased health acuity.4 A study about challenges to hospital discharge planning in Missouri revealed that hospitals have difficulty in finding nursing homes that will accept patients with complex health care needs such as dialysis, chemotherapy, radiation therapy, wound vacuums, and mental health needs.3 The study, however, did not identify why it was difficult to find placement for patients who had these conditions. To overcome this gap in knowledge, a survey was developed to learn from the nursing facility perspective the challenges faced in transitioning residents to skilled nursing facilities from hospitals. This article reports on the findings from that survey and describes the nursing home staff’s perspective of challenges with hospital to nursing home transitions. RESEARCH DESIGN AND SPECIFIC AIM This descriptive study used a cross-sectional Web-based survey targeted to health care 103
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
104
JNCQ-D-13-00176
February 3, 2014
23:17
JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2014
teams in nursing homes involved with admitting residents from hospitals to nursing homes. The specific aim was to describe the types of problems encountered by nursing homes when admitting residents from hospitals. Data collection procedure and sample After obtaining institutional review board approval, survey respondents were contacted via the Quality Improvement Program of Missouri (QIPMO) nurses’ list serve network. The QIPMO program offers expert nurse consultation to nursing homes to support quality improvement and facilitate systems change in nearly 500 nursing facilities.5 An e-mail invitation and link to the electronic survey was sent to each QIPMO nurse who in turn posted it to his or her list serve of nursing home contacts for the QIPMO program. The survey invitation was sent to contacts from 474 nursing homes in Missouri. Respondents were asked to complete 1 survey per home and to describe which team members contributed to survey completion. Instrument The original hospital survey3 was adapted for nursing homes by a multidisciplinary team composed of 2 doctoral prepared nurse researchers who are advanced practice registered nurses board certified in gerontology, and a doctoral prepared social worker. In addition, a review of the literature about problems with discharges from the hospital was undertaken, and the survey was revised to reflect these challenges described in the literature. Content validity of the survey was established in 2 ways. First, nurses from QIPMO reviewed the survey and offered suggestions for improving the questions for clarity, anchors, and flow. In addition, they were asked whether there were any issues that were not addressed in the survey. Second, the primary investigator (LLP) then met with 2 QIPMOsponsored support groups that represented 6 different nursing homes and were composed of minimum data set coordinators, administra-
tors, and directors of nursing to review each question and anchor to identify questions that were not relevant or were unclear. There were no substantive changes suggested, but instructions and slight changes to the wording of the questions were made on the basis of their recommendations. The survey comprised 81 Likert-type and short answer questions about problems with resident transfers from hospitals to nursing homes. First, respondents were asked to rate how willing they are to accept residents with certain types of problems or needs. Scores ranged from 1 (very willing) to 5 (never willing) to accept. Second, nursing homes were asked to rate the frequency with which they encounter problems when admitting residents from the hospital. Scores for that scale ranged from 1 (very often) to 5 (never) encountered the problem. At the end of each scale, there were opportunities to provide additional information. Finally, there were opportunities to respond to questions about useful strategies for communication with hospital personnel and about what can be done to improve communication between hospitals and nursing homes. Analysis For each question in the survey, the results were summarized using the Genmod procedure in SAS V9 (SAS Institute Inc, Cary, North Carolina). A Tukey-Karmer adjustment for multiple comparisons among different conditions was used. Differences were considered statistically significant if the adjusted P value was less than .05. A content analysis of the short answer questions was done. Answers were sorted by question, like responses were counted for each question, and finally answers were categorized into general types of issues or problems by the principal investigator. Coinvestigators reviewed the short answers and the initial coding categories and then the group discussed revisions and made adjustments on the basis of group consensus. Items and problems were grouped into broader categories.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00176
February 3, 2014
23:17
Hospital to Nursing Home Transition Challenges RESULTS Sample Nursing homes were asked to complete a single survey per site using the perspective of multiple team members. There were 475 survey links distributed; 178 (38%) surveys were returned from all 7 geographic regions of Missouri. Job categories of respondents included licensed nurses, directors of nursing, minimum data set coordinators, physicians, social workers/social work designees, case managers, managers/administrators, and physical or occupational therapists. Nearly 70% (n = 117) of the homes were for-profit, and the remainder (n = 52) were not-for-profit. Just under 60% (n = 105) of homes were of bed size between 61 and 120 beds, nearly 30% (n = 52) were of more than 120 beds, and the remainder (n = 19) were of 60 beds or lesser. Nearly 80% (n = 139) of respondents reported that their facility was 10 miles or less from the nearest hospital, 16% (n = 28) of respondents reported being within 25 miles from a hospital, and only 6% (n = 10) reported being 50 miles or less. One facility was 75 miles from the nearest hospital. Willingness to accept transfers There was variation in the degree of willingness of nursing homes to accept hospital residents with a variety of medical conditions or needs. Residents with treatments that nursing homes were not willing or never willing to accept included those who require a ventilator (P < .05), total parenteral nutrition (P < .05), and use of a sitter (P < .05) (Table 1). Medical conditions and patients with other needs that nursing homes were less willing to accept at transfer included behavior management problems, wound vacuum, tracheostomy, infection requiring isolation, chemotherapy, radiation therapy, mental illness, morbid obesity, and developmental disability (Table 1). Sixty-eight respondents provided additional information about other medical conditions or issues that affected their willingness to accept residents from hospitals. Mentioned
105
most frequently as influencing their willingness to accept patients were high costs of care (n = 17). Nursing homes also noted that they were unlikely to admit residents who have the potential for behavior that placed other residents or the organization at risk for problems, such as elopement potential (n = 10), aggressive or combative behaviors (n = 9), sex offenders or known criminal history (n = 5), substance abuse (n = 4), and suicide risk (n = 4). Organizing transfers Nursing homes were asked to rate how often they encountered specific problems during hospital transitions. The Supplemental Digital Content Table, available at http://links. lww.com/JNCQ/A61, describes the problems in rank order of occurrence. The issues viewed as most problematic by nursing homes included lack of communication between the hospital physician and the accepting physician, advance health care directives not being sent, patients’ routine medication being changed during the hospitalization, and resident’s condition worse than expected on arrival. Problems reported as less problematic were mental illness, infection, new injuries not reported, and no verbal report given. There were no statistically significant differences in reported problems. Sixty-three respondents made additional comments about problems encountered at the time of transfer. Nearly 30 respondents indicated that there were often problems with physician orders including contradictory or missing orders, omitted prescriptions for opioid medications, and order changes made immediately prior to hospital discharge. Twenty respondents reported that they received too much information from the hospital that was hard to understand, not timely, not readable, or for the wrong patient. Another 20 respondents specifically identified problems related to late or poorly timed admissions, for example, meal times or late in the day, transportation issues, and expensive procedures not done prior to hospital discharge or ordered after nursing home admission.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00176
106
February 3, 2014
23:17
JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2014
Table 1. Medical Conditions and Willingness of Nursing Homes to Accept Hospital Patients, Ranked From Least to Most Willing Medical Condition/Treatment Ventilator Total parenteral nutrition Requires a sitter Behavior management problem Tracheostomy Morbid obesity Infection requiring isolation Chemotherapy Mental illness Developmental disability Radiation therapy Wound vacuum Hemodialysis Transportation to and from medical appointments Fall risk Intravenous therapy Pressure ulcer Dementia Dressing change Requires physical and/or occupational therapy Diabetes a1
n
Mean Scorea
SD
Rank
168 168 167 171 172 168 171 170 171 171 168 172 172 168
4.82b 3.89b 3.63b 2.78 2.74 2.52 2.32 2.27 2.22 2.19 2.19 2.17 1.79 1.68
0.5 1.5 1.06 0.94 1.37 1.20 1.16 1.30 1.08 1.20 1.24 1.31 1.08 0.94
1 2 3 4 5 5 7 8 9 10 11 12 13 14
169 172 172 172 173 173
1.46 1.42 1.33 1.23 1.18 1.07
0.70 0.89 0.56 0.49 0.41 0.26
15 16 17 18 19 20
173
1.05
0.22
21
= very willing, 2 = willing, 3 = somewhat willing, 4 = not willing, 5 = never. significant difference from other conditions/treatments.
b Statistically
Nursing homes were divided in their willingness to admit residents on the weekends, with more than half (n = 98) responding that they would very often or often accept weekend admissions. Although nearly 90% of nursing homes reported that they were unlikely to request a delay in transfer, 125 respondents commented about specific reasons they would request a delay such as for a new or unstable medical condition (n = 24). It is worth noting that a number of nursing home respondents identified challenges related to human or material resources as a reason for transfer delay including lack of availability of equipment or supplies (n = 49), inability to secure medications including narcotic prescriptions (n = 27), late in the day or weekend referrals
(n = 12), and nursing home staff and physician availability (n = 11). Medications and treatment orders Respondents were asked to rate on a scale of 1 to 5 how often they had difficulty obtaining medications within 24 hours after hospital discharge. Lower scores indicate more problems. Of the 147 responses, the only statistically significant problem was not having a signed controlled substance prescription available (mean: 2.6, SD: 1.2, P < .05). Other items were transfer orders requiring clarification (mean: 2.9, SD: 1.0), pharmacy services not available at night (mean: 3.5, SD: 1.3) or on the weekend (mean: 3.7, SD: 1.17), needed medications not available
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00176
February 3, 2014
23:17
Hospital to Nursing Home Transition Challenges from dispensing pharmacy (mean: 3.6, SD: 0.86), and common medications not available in emergency kit (mean: 3.6, SD: 0.94). Of the 68 who commented on medications that were difficult to obtain within 24 hours, 37 identified narcotics, followed by antibiotics (n = 11). Next, respondents were asked to describe how much time on average they spend in activities related to callbacks and clarifying orders. Of 153 respondents, 20% spend less than 30 minutes making callbacks and clarifying orders, about one-third (n = 55) spend 30 minutes to 1 hour, nearly another third (n = 45) spend 1 to 2 hours, and slightly more than 13% (n = 21) spend 2 to 3 hours. In terms of the average time spent reconciling medications, just below 10% (n = 11) spend less than 30 minutes, nearly half (n = 74) spend 30 minutes to 1 hour, about a third (n = 53) spent 1 to 2 hours, and the remainder (n = 12) spend more than 2 hours. Finally, on the topic of medications, respondents described activities that take the most time when reconciling medications. The majority of the 112 respondents who responded to this question cited having to overcome challenges when encountering unclear orders (n = 62) and having to “decipher” or “figure out” (n = 31) orders that are incomplete, illegible, or confusing. They clarified orders through activities such as reviewing transfer documents and communicating with others (n = 31) including contacting the physician and waiting for return calls (n = 38). Communication Respondents were asked to identify strategies to improve communication with hospitals. Nearly half (n = 38) indicated that it would be helpful to talk to a single knowledgeable person about the resident. Respondents expressed frustration about the lack of consistency in hospital nursing staff and encountering staff who did not know the residents and yet were giving reports about them. Nursing home staff expressed frustration when they called the hospital with questions about a resident, and no one with knowledge of the in-
107
dividual was available to speak with them. Strategies to overcome these issues include a name and callback number for contact, speaking with a single identified person such as a social worker, use of standardized reports such as INTERACT (Interventions to Reduce Acute Care Transfers), or meeting residents face-toface in the hospital. DISCUSSION It is well documented that at the time of transition from the hospital, many patients require extensive rehabilitation and recuperation. As with all settings, nursing homes vary in their ability to manage residents recently discharged from the hospital. It was clear from this survey that there are common problems with hospital transition to the nursing home that stress the human, material, and financial capacity of the nursing home. Perhaps the most significant issue is that nursing homes have limited registered nurse resources to manage residents with complex needs.6 Yet, many residents come to nursing homes from hospitals with significant ongoing care needs for problems such as renal failure requiring hemodialysis, complex wounds, infections, postsurgical care and rehabilitation, and chronic disease management. These complex patients need equipment, treatments, and medications that are not readily available in many nursing homes, requiring that hospitals carefully communicate patients’ needs so that residents’ ongoing care needs can be accommodated. Patients’ needs may be better met if hospitals and nursing homes move toward managing the common problems that affect residents at the time of transition. For instance, it is important for hospitals to know what type of care is available in nursing homes so that services may be continued without interruption at the time of transition between hospital and nursing home. Nursing homes expressed a reluctance to accept patients with behavioral problems and will not accept patients who require individual attention such as those needing a sitter. In a previous study, it was noted that patients
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00176
108
February 3, 2014
23:17
JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2014
Table 2. Process Recommendations for Transitional Improvement Hospital Communicate needed equipment in time for nursing homes to obtain it prior to transfer Communicate drugs or treatment that may require preauthorization well in advance of potential discharge Send narcotic prescriptions with resident
Institute provider-to-provider communication prior to discharge Discharge early in the day so that there is time for communication with transferring staff Identify residents’ problem behaviors including history, duration, and potential triggers to nursing homes
with mental health care needs were difficult for hospitals to place.3 Our research team surmised that the reluctance to accept those patients is because of the nursing home staff’s concerns about behavior, a lack of training and expertise about behavioral health, and the risk that problem behaviors pose for residents’ safety. The findings from this study support the assumption that it is residents’ behavior that in part makes nursing home admission problematic. Nursing homes are willing to consider accepting residents with a variety of behavioral issues ranging from the potential for elopement; combative, aggressive, or sexual aggressive behavior; substance abuse; and risk for suicide. Nursing homes may not be the appropriate place to care for people with extreme behavior problems, yet there are few postacute alternatives.6 Hospitals and nursing homes must work together to arrive at workable, safe solutions to these problems. Another major problem that places residents at risk for interrupted care or treatment is the access to medications by nursing homes. Narcotic prescriptions were particularly problematic because of the need for a signed nar-
Nursing Home Analyze nursing home capacity to care for residents with specific health care conditions Communicate to hospitals what drugs or treatments require authorizations Verify that narcotic prescriptions have been written and identify plan for obtaining the prescription if missing Identify provider-to-provider plan of communication with nursing home medical director or admitting physician Request transfer early in the day. If not possible, request name and phone number of after-hours provider contacts Identify whether behaviors can be successfully managed by identifying critical features of the behavior such as history, duration, and triggers
cotic prescription to obtain these medications from the pharmacy. When these signed prescriptions do not accompany residents to the nursing home, there is no practical way for the nursing home to obtain these medications, which may result in interrupted pain management. Many nursing homes do not have ready access to pharmacy services 24 hours a day.7 Preauthorization of medication is an emerging problem. Hospitals need to alert nursing homes about medications that are unusual or expensive, so plans for obtaining these medications can be made several days prior to the resident’s hospital discharge. In reality, medication orders that are unclear or require follow-up create barriers to the nursing home’s ability to provide safe uninterrupted care.8 An impediment to ongoing care is the lack of consistent medical providers across settings.9 The use of primary care physicians who cross all settings is becoming increasing rare.10 It is challenging for a nursing home to call back to a discharging hospital and get orders clarified; the physician who initiated the order may be gone, as is the nurse who had knowledge of the resident. To
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00176
February 3, 2014
23:17
Hospital to Nursing Home Transition Challenges overcome this problem, nursing home staff recommended obtaining the name and number of a contact person to call if there was a problem. They also identified social workers as a good contact, providing nursing homes with a single person who was knowledgeable about the resident and hospital stay. Improving hospital to nursing home provider-toprovider communication is vital. In general, communication with hospitals was problematic. The nursing homes reported that patients are often transitioned late in the day or on Friday afternoons. The nurse giving report was frequently not the person who had cared for the patient during the day, and if clarification was needed, the nurse was unable to answer questions about the resident. Table 2 outlines some protocol recommendations on the basis of the responses received from respondents in this study. Programs such as INTERACT have tools available to streamline and improve information exchanged during transition.11
109
CONCLUSION To solve problems with transfers from hospitals to nursing homes, it is important to understand the challenges faced by nursing homes that accept hospital patients for admission. Nursing homes are willing to accept challenging residents from hospitals provided they are given adequate information about equipment, medications, and behavioral needs, so that the correct resources can be arranged and put into place prior to patients’ transition. It is vital that plans for communication after the transition be in place for nursing homes to have access to staff or providers who can clarify orders. Process recommendations are provided to highlight the changes that are needed to improve transitions from hospitals to nursing homes. Given the increase in residents’ acuity and need for nursing home care, it is time to address the issues identified in this article.
REFERENCES 1. Centers for Medicare & Medicaid Services. Nursing home data compendium, 2012 edition. http:// www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/downloads/ nursinghomedatacompendium_508.pdf. Accessed October 11, 2013. 2. Ness J, Ahmed A, Aronow WS. Demographics and payment characteristics of nursing home residents in the United States: a 23 year trend. J Gerontol A Bio Sci Med Sci. 2004;59(11):1213-1217. 3. Popejoy LL, Galambos C, Moylan K, Madsen R. Challenges of hospital discharge for rural and urban older adults. Clin Nurs Res. 2012;21(4):431-449. 4. Toles M, Young HM, Ouslander J. Improving care transitions in nursing homes. J Am Soc Aging. 2013;36(4):78-85. 5. Rantz MJ, Cheshire D, Flesner M, et al. Helping nursing home “at risk” for quality problems: a statewide evaluation. Geriatr Nurs. 2009;30(4):238-249. 6. Seblega BK, Zhang NJ, Unruh LY, Breen GM, Paek SC, Wan TH. Changes in nursing home staff staffing
7.
8.
9.
10.
11.
levels, 1997-2007. Med Care Res Rev. 2010;67(2): 232-246. Vogelsmeier A, Scott-Cawiezell J, Zellmer D. Barriers to safe medication administration in the nursing home. J Gerontol Nurs. 2007;33(4):5-12. Vogelsmeier A, Scott-Cawiezell J, Pepper G. Medication reconciliation in nursing homes: thematic differences between RN and LPN staff. J Gerontol Nurs. 2011;37(12):56-63. Boockvar KS, Burack OR. Organizational relationships between nursing homes and hospitals and quality of care during hospital-nursing home patient transfers. J Am Geriatr Soc. 2007;55(7):1078-1084. Bodenheimer T. Coordinating care—a perilous journey through the health care system. New Engl J Med. 2008;358(10):1064-1071. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project. J Am Geriatr Soc. 2011;59(4):745-753.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
