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


Program Implementation

The System Efficiency Project was implemented by the Hospital Executive Council, the Long Term Care Executive Council, and their member organizations on December 18, 2002. All 4 hospitals and all 12 nursing homes in the Syracuse metropolitan area participated. The essential component of the program, the development and distribution of patient lists, experienced some difficulties but was in place by the first week of January 2003. Lists of nonacute, alternate care patients had been assembled from the hospitals and distributed by the Hospital Executive Council for several years. This population was widened to include all difficult-to-place patients, including those who were still receiving acute care. The distribution of the list was increased to 2 times per week via email to all nursing homes and home health agencies in the community.

By mid-January 2003, the System Efficiency Project was fully operational at all of the Syracuse hospitals and nursing homes. At that time, the Hospital Executive Council initiated the distribution of a weekly summary report on project activities. This report included numbers of difficult-to-place patients admitted by hospital of origin and receiving nursing home. Rates of admission of these patients per nursing home bed were also included.

During the initial months of the System Efficiency Project, both hospital and nursing home staffs reported increased activity in the placement process. Nursing home admission coordinators confirmed that hospital care managers were working more aggressively to identify candidates for placement earlier in their stays. The activity of nursing home admissions staff also increased during this period. Hospital care managers reported more screening activity by nursing home admission coordinators and requests for the patient lists and related data.

As the System Efficiency Project proceeded, periodic meetings of hospital care managers and nursing home staffs were held to provide progress updates and address specific issues. These discussions helped reinvigorate the identification process at a number of the hospitals.

Impact on Utilization and Outcomes

The cooperative projects involving acute care and long-term care providers in Syracuse improved patient outcomes by increasing the accessibility of care for a number of specific populations in the community. The cooperative projects also improved the efficiency of healthcare in the community by reducing delays in the movement of patients between settings. This improvement was best demonstrated by reductions in hospital stays and nonacute care during the period after initiation of the projects.

Data concerning hospital lengths of stay for discharges to nursing homes in Syracuse during this period are summarized in Table 2 . Utilization for the first quarters of each calendar year were used to allow seasonally adjusted comparisons with the most recent information.

These data demonstrate that mean stays for the combined hospitals declined by 2.5 days, from 12.1 to 9.6 days between January 2000 and March 2004. During this period, the numbers of discharges to nursing homes increased from 1370 to 1851. It should also be noted that, because of the reduction in stays, the total patient days for this population declined despite the increase in discharges.

Additional information concerning the impact of the program on lengths of stay was provided by an analysis of alternate or nonacute care utilization in the Syracuse hospitals. These patients generated hospital stays that are so long that they exceed acute care. The results of this analysis are summarized in Table 3 .

The data in Table 3 demonstrate that the community-wide alternate care census declined by 6.4 patients, or 18.1% between the first quarters of 2000 and 2002, before the cooperative projects were implemented. Between 2002 and 2004, as the projects were implemented, the alternate care census declined by 17.6 patients, or 60.8%. These developments were reflected in the experiences of the individual Syracuse hospitals. During the 5-year period, the mean alternate care census of each hospital declined by at least 46%.

Additional data identified changes in numbers of difficult-to-place patients admitted to local nursing homes during the implementation of the cooperative projects. This information is summarized in Table 4 .

These data demonstrate that the total number of difficult-to-place patients admitted from hospitals by nursing homes in Syracuse varied during this period. The largest number (256) was admitted during the first quarter of 2002, followed by lower volumes in subsequent quarters. One interpretation of the data is that a certain critical mass of difficult-to-place admissions was necessary to start the cooperative programs, after which the system made internal adjustments to improve the efficiency of utilization.

Evaluation of the data concerning difficult-to-place patients also indicated that a limited number of facilities and beds shouldered a disproportionate share of difficult-to-place admissions. During the 15-month period, Loretto and Rosewood Heights, which include 24.5% of the nursing facility beds in the system, admitted 44.9% of the difficult-to-place patients. Similarly, Loretto, Rosewood, St. Camillus, and James Square, which account for 49% of the beds in the system, admitted 68.9% of the difficult-to-place patients.

Additional information concerning operation of the cooperative programs in Syracuse concerned the medication programs that were developed between the hospitals and nursing homes. Information concerning the initial 15 months of the intravenous antibiotic therapy program are summarized in Table 5 .

These data demonstrate that this initiative has served limited numbers of patients and has involved a few large providers. Between January and December 2003, the program served 48 patients, 30% of the estimated number of candidates. Two facilities, Loretto and Rosewood, accounted for 77% of the patients. The initial experience of the intravenous therapy program in Syracuse suggested that over 1000 patient days were avoided in hospitals during the first 5 quarters of the effort.

Additional data concerning the program indicated that admission levels were constrained by the high cost of the intravenous medications, the staff levels required in nursing facilities, and the limited amount of program development funding available. Medications used most frequently by patients admitted included relatively low-dose vancomycin hydrochloride ( Vancocin ), which accounted for 22 patients (45.8% of the total) and oxacillin sodium (25% of the total). Other intravenous medications provided through the program included cefazolin sodium ( Ancef , Kefsol ), ampicillin sodium ( Unasym , Polycillin ), gentamicin sulfate ( Gentamicin ), and piperacillin sodium-tazobactam sodium ( Zosyn ).

The oral and subcutaneous medications program was implemented on February 27, 2004. During its first month of operation, it supported the admission of 10 difficult-to-place patients in nursing homes in the Syracuse area. All of these patients were admitted to either Loretto or Rosewood Heights. Medications most frequently associated with these admissions included pantoprazole ( Protonix ), epoetin alfa ( Procrit , Epogen ), and enoxaparin sodium ( Lovenox ). Sufficient utilization of this program has not occurred to permit generalizations concerning its impact.


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