A Community-wide Program to Improve the Efficiency of Care Between Nursing Homes and Hospitals

Ronald J. Lagoe, PhD; Janet Dauley-Altwarg, JD, MHA; Saundra E. Mnich, MSN, RN-C; Lynn M. Winks, RN, AAS


Topics in Advanced Practice Nursing eJournal. 2005;5(2) 

In This Article


During 2002, the interest in expediting the movement of patients between hospitals and long-term care facilities once again gained attention in the Syracuse area. Hospital emergency departments experienced frequent overcrowding because of the inability to access floor beds. Medical and surgical inpatient beds were usually at or near capacity because of long-stay patients who could not gain access to appropriate long-term care services.

An analysis of systemwide data by the Hospital Executive Council, the planning organization of the Syracuse hospitals, demonstrated that among all discharge statuses during 2001 and 2002, patients discharged to nursing homes produced the largest number of patient days in excess of the national average in the Syracuse hospitals (25,000-30,000 days). The study also demonstrated that differences between mean lengths of stay in the Syracuse hospitals and severity-adjusted national averages were longest for discharges to nursing homes (5.2-6.7 days). This analysis is summarized in Table 1 .[15,16]

Discussions of these issues between the Hospital Executive Council and the Long Term Care Executive Council, which represents local nursing homes and home health agencies, led to the development of a planning process to address these issues. The objective of this process was to improve the outcomes and efficiency of the healthcare systems by expediting the movement of patients to appropriate services. Unlike previous efforts, this process was developed to address these objectives without expanding the nursing home bed capacity of the community.

After reviewing data related to outcomes and efficiency for acute care and long-term care providers in Syracuse, participants in the process concluded that the focus of activity should be expediting the movement of hospital patients to nursing homes who experienced delays in accessing these facilities. Available evidence indicated that this situation limited access to acute care by occupying additional inpatient medical-surgical beds in a system constrained by a shortage of nurses. By limiting the movement of patients within hospitals, these delays also restricted access to emergency departments and ambulance services.

The planning process focused on the development of 2 types of programs to address delays in the movement of hospital patients to long-term care services. A general program, the System Efficiency Project, involved all hospitals and nursing homes and a wide range of patients. Specific programs involving the hospitals and some long-term care providers addressed the needs of patients requiring intravenous medications as well as high-cost oral and subcutaneous drugs.

System Efficiency Project

The development of a systemwide process for improving the efficiency of care involved reconciliation of 2 sets of needs. Hospitals required additional nursing home admissions for patients with multiple-care needs who generated extended stays. Nursing homes needed additional resources to meet the substantial needs for care generated by this population.

The principal obstacle proved to be the identification of a commodity that hospitals could provide in return for nursing home admission of difficult-to-place patients. These patients were identified by individual hospitals on the basis of historical experience for clinical and financial criteria. Difficult-to-place patients were most frequently those with multiple chronic diseases and limited reimbursement. Financial subsidies were ruled out because they could not be used for Medicare and Medicaid patients. Almost all difficult-to-place patients in the hospitals were reimbursed by public payers. Referrals of patients attractive to nursing homes, such as those with substantial rehabilitation potential and private funds, were also suggested. This approach proved to be impractical because of the staff time required to track large numbers of referrals to nursing homes.

In December 2002, the planning process developed a mechanism that involved hospital efforts to expedite the identification of patients who were appropriate for nursing home placement and attractive to these providers at an earlier point in their acute care stays. These included patients with substantial rehabilitation potential and those with private funds. At the conceptual level, this process linked better hospital identification of these patients with nursing facility admission of larger numbers of difficult-to-place patients from the acute care facilities.

Although it was impractical for hospitals to identify all potential referrals to nursing homes, the participating acute care facilities were able to develop lists of difficult-to-place patients. A list of difficult-to-place patients for all 4 hospitals was distributed through email by the Hospital Executive Council 2 times each week. This list included a facility identifier, hospital admission date, age, major clinical and functional diagnoses, and probable long-term care payer status for each patient. The list included only difficult-to-place patients.

By focusing on a provision of information concerning large numbers of patients, the project avoided difficulties associated with managing individual referrals. Preferences of individual patients for specific nursing homes continued to be honored, although most candidates for placement were willing to consider more than 1 facility.

Intravenous Therapy Program

The intravenous therapy program also addressed the needs of patients who generated long stays in the acute care system. Many patients in hospitals who required extended intravenous therapy could not be discharged home with support services because of the lack of suitable home environments and/or informal caregivers. An analysis developed by the Hospital Executive Council identified 81 intravenous antibiotic therapy patients in the Syracuse hospitals who could have been discharged home during a 12-month period in 2002. The mean hospital stay for these patients was 32 days. It was estimated that each of these patients could have been discharged to a nursing home to complete intravenous therapy no later than the 10th day of the hospital stay.

Development of a long-term care program to meet the needs of this group required the creation of intravenous therapy services in local nursing homes and the incentives to support such efforts. Through a task force comprised of acute care and long-term care representatives, 4 local nursing homes committed to develop intravenous antibiotic therapy services. In order to implement the specific programs, each of these facilities was paired with a hospital in-service education department. Between November 2002 and January 2003, the nursing home core staffs were provided with the necessary education in intravenous therapy. The core staff members then educated their associates at each of the long-term care facilities.

Another major challenge in the development of this program was finances. High costs of intravenous pharmaceuticals and related supplies were a major deterrent to the use of this therapy in nursing home facilities. Medicare and Medicaid regulations prohibited hospitals from subsidizing this form of care on a patient-specific basis.

This obstacle was surmounted through the development of a community-wide intravenous therapy program of which the objective was to improve the accessibility of care. Through the guidance of legal counsel, the hospitals and nursing homes developed a system of funding intravenous therapy in nursing homes through program development funds. These funds were assigned by the individual hospitals to a community-wide pool maintained by the Hospital Executive Council. The funding was allocated to nursing facilities as a contribution to program development. For each participating nursing facility, the amount of program development funding was prorated to the number of individuals served without regard to each patient's diagnosis, medication, discharging hospital, or admitting nursing facility. Through this approach, accessibility of care for this population was supported without subsidizing individual patients.

Oral and Subcutaneous Medications Program

Through operation of the System Efficiency Project, it became apparent to the hospitals and nursing homes in Syracuse that factors, such as the cost of oral and subcutaneous medications, were limiting the ability of long-term care facilities to admit many patients. With the assistance of legal counsel, they developed a community-wide pool to provide program development funding for certain oral and subcutaneous medications. This pool was similar to the one developed for the intravenous medication program. As in the case of the intravenous medication program, funding was prorated by service volume at a single level, without respect to the medication, dosage, patient diagnosis, discharging hospital, or admitting nursing facility. The procedures for this program stipulated that hospital patients would have to appear on the community-wide, difficult-to-place list before becoming eligible for participation and pool funding.

Summary of Programs

All of the programs described above are operated jointly by the Syracuse hospitals and nursing homes through the Hospital Executive Council and the Long Term Care Executive Council. This process is summarized in the Figure.


Community-wide programs: Hospital Executive Council and the Long Term Care Executive Council, Syracuse, New York.


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