Reducing Hospital Stays for Patients Discharged to Nursing Homes: An Evolving Program

Ronald J. Lagoe, PhD; Cheryl Noetscher, MS, RN; Anne Vargason, MSW; Mark Buttiglieri, MSW


Topics in Advanced Practice Nursing eJournal. 2008;8(2) 

In This Article

Abstract and Introduction

Context: This project addressed the need to reduce hospital lengths of stay for patients who are difficult to place in nursing homes. This delay is a major issue with hospitals that need to improve inpatient bed turnover to admit patients from emergency departments and other locations.
Objective: The objective of the project was to reduce hospital stays for difficult-to-place patients discharged to nursing homes.
Setting: The project was implemented in the metropolitan area of Syracuse, New York, with a population of 447,832 (2007). This area included 4 general hospitals and 12 nursing homes.
Interventions: The first intervention concerned distribution of lists of difficult-to-place hospital patients to all nursing homes and home health agencies in the community. The second intervention involved the development and implementation of a series of subacute programs for specific therapies in nursing homes.
Results/Principal Outcomes: The project demonstrated that between 2005 and 2007, the mean hospital stay for discharges to nursing homes was reduced by 2.2%, and the annual number of difficult-to-place patients admitted to nursing homes increased by 17.7%. It is believed that the new initiatives contributed to these developments.
Conclusions: Progress can be achieved in reducing stays for hospital patients discharged to nursing homes. This process evolved over time because of the complexity of the issue and the need to take advantage of actual experience.

The efficient and effective movement of patients between hospitals and nursing homes is a major challenge for healthcare systems throughout the United States. The magnitude of this challenge has increased as patient populations have aged and require more complex postdischarge care.[1,2]

In the United States and Canada, a variety of approaches have been employed to maintain continuity of care between acute providers and providers of long-term care. Hospital-based case management programs have met with limited success.[3] Diagnosis-specific initiatives have generated promising results but only for specific conditions such as falls, hip fractures, and trauma care.[4,5,6,7] Innovative programs also have included the development of specialized acute care for the elderly (ACE) units.[8]

Efforts by hospitals to control the movement of patients between acute and long-term care by providing incentives to nursing homes to accept long-stay patients have not succeeded.[3] Provider networks with control over both hospitals and nursing homes can improve coordination of care among their own facilities but not among entire communities.[9]

Available data indicate that the aging of populations and the growing sophistication of medical care in the United States and Canada are increasing the numbers of patients with extended stays who are difficult to place in nursing homes and home health services. Unless improvements are made in the accessibility of long-term care services for these populations, they are likely to congregate in acute hospitals and compromise the ability of these facilities to provide emergency and inpatient care.[10,11,12,13]

Healthcare systems in many areas are struggling with the need to serve patients with extended stays by improving the movement of these individuals to long-term care services. The number of hospital patient days consumed by elderly patients aged 65 years and with extended stays continues to increase.[9,11] In the absence of direct control over the nursing home beds required to admit these patients, hospitals have been left with few options to provide appropriate postdischarge care.[14]

This article describes ongoing programs developed to reduce lengths of stay (LOS) for hospital patients requiring nursing home placement in the metropolitan area of Syracuse, New York. The study focuses on the most recent phases of the program involving patients who stay for extended periods in hospitals and could not be served through initial subacute program development. Three initiatives were devised to address the needs of these patients:

  1. Electronic distribution of patient data;

  2. Use of uniform definitions of these patients among different hospitals; and

  3. The development of additional programs for patients requiring medications, planning for total parenteral nutrition, frequent suctioning, and off-site services.

Earlier phases of this project have been described previously. These included the initial development of a system for distribution of data concerning patients identified as difficult to place from hospitals to nursing homes and other long-term care facilities, and the planning and implementation of subacute programs to support the movement of hospital patients to nursing homes for intravenous (IV) therapy, high-cost oral medications, and extensive wound care.[15,16]


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