Community-Wide Programs to Support Hospital Discharges to Nursing Homes

Ronald Lagoe, PhD; Cheryl Noetscher, MS, RN; Ann Markle, MS, RN; Pamela Johnson, CPA

Disclosures

May 05, 2010

Abstract

Context. As demographics change and young populations decline, many US communities are challenged with the need to provide care to increasing numbers of elderly patients.

Objective. This study describes the development of a series of programs to address the needs of hospital patients who require postdischarge care in nursing homes.

Desired outcomes. The programs were designed to improve patient care by decreasing hospital stays and expediting the provision of residential services in nursing homes.

Setting. The study involved the 4 acute hospitals and 12 nursing homes of Syracuse, New York. In 2008, this area had a population of 446,065.

Principal outcome measures. The principal measures included hospital lengths of stay for patients discharged to nursing homes compared with severity-adjusted national averages, utilization of specific initiatives, and the need for new programs.

Results. Between 2002 and 2008, the mean length of stay in the Syracuse hospitals for patients discharged to nursing homes declined by 2.5 days. The amount of excess utilization declined by 6711 patient-days. A total of 18,505 excess days remained in 2008. This utilization is being addressed through development of programs for mental illness, ventilator care, and financial and family issues.

Conclusions. This study demonstrated that it is possible to improve patient outcomes by expediting the movement of hospital patients to residential care.

From Hospital to Nursing Home

Historically, reducing hospital length of stay and maintaining continuity of care for patients discharged to nursing homes are challenges for nursing professionals in acute and long-term care. The movement of patients from hospitals to residential care facilities is often impeded by such issues as complicated care requirements, lack of sufficient nursing home beds, and financial considerations.[1,2]

During the past 25 years, interest in improving and expediting the movement of hospital patients who require placement in residential care has been stimulated by clinical and financial issues. The clinical challenges of caring for patients with complicated care needs who require nursing home placement are not new.[2,3] This situation has been exacerbated by increases in elderly populations in many communities.

Since the 1980s, hospitals in the United States have been reimbursed by payments per discharge, which encourages reduction in length of stay in order to improve the efficiency of care. Efforts to reduce stays have often focused on candidates for nursing home placement because these patients tend to generate the longest acute care stays.[4,5]

In the 21st century, government efforts to constrain Medicare costs have further encouraged hospitals to reduce inpatient stays. The same pressures have been generated by state-funded Medicaid programs. During 2008 and 2009, these pressures have intensified as federal and state governments have experienced revenue shortfalls related to the economic recession.[6,7]

Paradoxically, some of the same factors stimulating better movement of patients from hospitals to nursing homes have also impeded this process. Long-term economic difficulties in states such as New York have led to reductions in nursing home bed capacity. The economic recession has produced large state budget deficits and limited the funds available for Medicaid payments to nursing homes.[7,8]All of these factors drive the need to improve the transition of patients from hospitals to nursing homes, especially for patients with extended inpatient hospital stays. Historically, this population has not received the clinical or administrative attention devoted to patients who require short-term rehabilitation and for whom reimbursement is more financially advantageous.[9,10]

This study describes the evolution of a series of nursing and administrative initiatives for reducing stays for this population in the metropolitan area of Syracuse, New York, an area with a growing elderly population. These programs were developed by nurses in hospitals and long-term care facilities to encourage the efficient movement of patients between acute care and residential care within a healthcare system with limited resources. The movement of patients is measured by hospitals as length of stay. Some programs have already been implemented and others are works in progress. These are practical initiatives, developed with limited provider funds rather than extensive grants, to address the kind of length-of-stay issues that frequently confront caregivers and administrators in hospitals and nursing homes.

Population and Methods

This study concerned the planning and development of programs to improve the movement of patients between hospitals and nursing homes in the metropolitan area of Syracuse, New York. This area includes 4 acute-care hospitals (2008 discharges, excluding newborns): Community-General Hospital (8853 discharges), Crouse Hospital (19,665 discharges), St. Joseph's Hospital Health Center (19,358 discharges), and University Hospital of the State University of New York Upstate Medical University (16,346 discharges). Historically, these hospitals have developed programs to improve efficiency and outcomes through the Hospital Executive Council. [11]

Table 1 describes the population of Onondaga County, the center of the service area of the Syracuse hospitals. Between 2000 and 2020, this population is projected to decline by 7.7%, from 458,336 to 423,235. During the same period, the population age 85 years and older, the group most in need of hospital and nursing home care, is projected to increase by 65.2%, from 7766 to 12,833. At the same time, the population age 18-64 years, including the nursing workforce for acute and long-term care, is projected to decline by 10.2%.[12]

Table 1. Resident County Population, Onondaga County, 2000-2020

Age of Residents (y)  Number of Residents
  2000 2005 2010 2015 2020
0-17 118,563 112,615 105,469 102,160 100,479
18-44 175,303 163,217 155,714 151,105 147,866
45-64 101,176 112,082 116,632 110,259 98,860
65-74 32,167 29,424 30,755 36,564 41,619
75-84 23,361 23,559 21,639 20,228 21,578
≥85 7766 10,469 12,322 12,930 12,833
   Total 458,336 451,366 442,531 433,246 423,235

Data from New York Statistical Information System.

 

These changing demographics have affected the utilization of the Syracuse hospitals. The inpatient populations of the hospitals have seen growth in numbers of frail elderly patients, who present clinical challenges for medical-surgical and nursing care management because of multiple diagnoses and the need for postdischarge services. The decline in numbers of younger adults results in fewer hospital patients with less complex care needs and shorter, more predictable stays. The population projections suggest that this situation will intensify as numbers of elderly increase and numbers of young adults decline.

Within these demographics, the Syracuse hospitals were challenged by the problems related to extended stays and patients who require nursing home placement. Stays for these patients had been reduced during the 1990s through an increase in nursing home beds and other programs, but utilization remained substantially higher than severity-adjusted national averages, as demonstrated by Table 2.

Table 2. Inpatient Medical/Surgical Mean Length of Stay by Discharge Status, Syracuse Hospitals, 2002[a]

Discharge Status Discharges Mean Length of Stay (d) Severity-Adjusted National Experience Length-of-Stay Difference Patient-days Difference
Self-care 26,282 3.7 4.0 -0.3 -7884.6
Home care 9788 7.9 6.3 1.6 15,660.8
Nursing home 5731 11.1 6.7 4.4 25,216.4
Deaths/transfers 4042 9.5 8.2 1.3 5254.6
   Total 45,843 6.0 5.2 0.8 36,674.4

[a]Data exclude rehabilitation.
Data obtained from Community General Hospital, Crouse Hospital, St. Joseph's Hospital Health Center, and University Hospital, State University of New Upstate Medical Center; National Hospital Discharge Study.

 

Table 2 shows that during 2008, patients discharged to nursing homes were the largest source of excess patient-days in Syracuse hospitals. At the unit level, the mean length of stay for this population was 4.4 days longer than the mean severity-adjusted national average length of stay. This excess was more than twice that generated by any other discharge status. This comparison was important because it involved discharge populations in Syracuse and at the national level with the same degree of illness according to the 3M™ All Patients Refined Diagnosis Related Group System. The mean stay for discharges to nursing homes, 11.1 days, was also 3.1 days longer than the mean stay for the total adult medical and surgical discharge population in Syracuse.

Measured by differences in mean stays multiplied by discharges, patients discharged to nursing homes generated 25,216 excess days in 2002. This amounted to 68.7% of all excess days for adult medicine and adult surgery. The number of excess days for discharges to nursing homes equated to an average daily census of 69.1 during 2002 for the combined Syracuse hospitals.

Among clinicians and administrators in the Syracuse hospitals, these data spawned renewed interest in reducing hospital length of stay. The substantial number of excess days produced by delayed discharges to nursing homes was slowing, was delaying new admissions at all of the area's hospitals, and was creating financial problems for the hospitals. At a late-stay rate of approximately $400 per day, the excess days were costing the combined hospitals an additional $10,086,400 annually. With reimbursement for all payors made on a per discharge basis, this additional cost was not being offset by added revenue.

System Efficiency Program

The Syracuse hospitals identified specific populations for interventions. Analyses conducted by the Hospital Executive Council demonstrated that discharges to nursing homes fell into 2 major categories. Patients with rehabilitation needs and relatively simple clinical conditions had hospital stays close to severity-adjusted benchmarks and did not require additional nursing interventions in acute or long- term care. On the other hand, patients with extended hospital stays who required nursing home placement for long-term care consumed more nursing resources and patient-days.

Before 2002, hospital efforts to reduce stays in Syracuse hospitals for patients who were to be discharged to nursing homes had focused on alternate-care patients, whose stays exceeded the end of acute care stays identified by utilization review processes. In 2002, care management directors of the 4 hospitals widened the definition of alternate-care patients to include difficult-to- place (DTP) patients, whether they exceeded the end of acute care or not. These patients included those with multiple chronic conditions, mental health diagnoses, complicated treatment needs, long-term-care payor issues, and family concerns. These factors, either individually or collectively, cause these patients to be unattractive to nursing homes.

To address the needs of DTP patients in Syracuse, hospital care management directors and the Hospital Executive Council worked with local nursing homes to develop the System Efficiency Program, which focused on more timely admission of DTP patients to long-term care facilities. Through the System Efficiency Program, the hospital care managers encouraged the movement of patients attractive to nursing homes, such as those requiring rehabilitation or those who had private pay as reimbursement, in return for nursing home admission of DTP patients. The increased referral of attractive patients to nursing homes was intended to sustain the ability of these facilities to admit at least 15% from the DTP category. The 15% objective allowed each nursing home to admit most of its patients from the non-DTP category and therefore did not create an undue burden on the admission process for any individual facility. Therefore, each nursing home still had considerable flexibility to admit most of its caseload from patients with lower care needs.[13,14]

Implementation of the System Efficiency Program was made the responsibility of hospital nursing care management departments and nursing home admission coordinators. In the hospitals, nursing care managers were responsible for the arduous work of the program, which involved expediting and brokering the movement of patients with nursing home staffs.

The program was monitored by the Hospital Executive Council staff. This was accomplished by distributing lists of DTP patients for the 4 hospitals, including summary clinical and utilization data, twice each week through email to all nursing homes and home health agencies in Onondaga County. A monthly distribution of tables that detailed numbers of DTP patients, total new admissions to nursing homes, and rates of DTP patient placement was also provided to all hospital care managers and nursing home admission staff. Table 3 summarizes the movement of DTP patients under this program between 2002 and 2009.

Table 3. Difficult-to-Place Nursing Home Placement and Rates, Syracuse Hospitals, 2002-2009

Variable 2002 2003 2004 2005 2006 2007 2008 2009 January-August
Number of patients                
   Community General Hospital 117 175 76 82 66 91 146 106
   Crouse Hospital 160 189 165 172 201 188 245 97
   St. Joseph's Hospital Health Center 386 387 440 508 516 522 499 283
   University Hospital - SUNY UMU 159 123 84 118 201 226 274 186
      Total 822 874 765 880 984 1027 1164 672
Difficult-to-place rate[a]                
   Community General Hospital 19.5 22.8 10.7 9.9 7.4 9.6 14.2 16.0
   Crouse Hospital 12.3 14.9 11.9 11.7 13.6 11.5 13.6 18.5
   St. Joseph's Hospital Health Center 19.0 15.2 15.1 16.7 18.8 16.3 22.4 8.0
   University Hospital - SUNY UMU 21.6 15.5 8.1 9.7 16.3 20.3 23.2 18.0
      Total 17.6 16.2 12.6 13.4 15.5 14.9 18.7 22.1

SUNY UMU = State University of New York Upstate Medical University
[a]Rates are based on actual difficult-to-place admissions divided by total new admissions to nursing homes.
Data obtained from Hospital Executive Council.

 

Table 3 demonstrates that numbers of DTP patients discharged by hospitals to nursing homes in the service area of the Syracuse hospitals dropped between 2002 and 2004 before increasing between 2004 and 2009. The initial decline can be attributed to difficulties in program implementation and the acquisition of consistent data. Between 2004 and 2008, the total number of DTP patients admitted by all nursing homes in the service area increased by 52.2%, from 765 to 1164. During the same period, the rate of admission of these patients increased by 48.4%, from 12.6% to 18.7%.

The success of the System Efficiency Program in increasing the movement of DTP patients to nursing homes was also reflected in an increase in the number of nursing homes that admitted at least 15% of their patients from this category from 4 nursing homes in 2002 to 9 in 2008. The success of the program was brought about through the efforts of nursing and other caregivers in both acute and long-term care facilities. As a result of this success, the community-wide objective for the DTP admission rate was increased to 20% in 2007.

Subacute and Transitional Care Programs

In addition to the System Efficiency Program, the care management directors of the Syracuse hospitals also worked to develop initiatives to expedite the movement to local nursing homes of patients who require specific types of care. The programs were developed through a planning process that included the hospital care management directors, the nursing home admission directors, and the Hospital Executive Council staff. The process involved the following activities:[14]

  • Identification of therapies that delayed the discharge of hospital patients;

  • Evaluation of the extent to which these therapies could be provided in nursing homes;

  • Identification of reimbursement levels that could support the provision of these therapies in nursing homes; and

  • Identification of program structures to implement this process.

The Subacute and Transitional Care Programs involved the provision of program development funding to nursing homes that admitted these patients. The structure of these programs included the following components: [14]

  • Participation of each patient in the program would be agreed to by the care management director of the discharging hospital and the admission director of the admitting nursing home;

  • All funding would be distributed through a community-wide pool maintained by the Hospital Executive Council;

  • Funding for each program would be provided at uniform rate per patient; and

  • Funding would be provided for a minimum of 3 patients per facility.

Program structures were implemented for each of the following therapies:

  • Intravenous medications;

  • Oral and subcutaneous medications;

  • Enhanced medications;

  • Extensive wound care;

  • Bariatric care; and

  • Off-site services

The Enhanced Medication Program was developed for a number of intravenous and oral medications that could not be addressed within community-wide funding levels for those programs. The Extensive Wound Care Program included wound vacuum-assisted closure-device services. The Off Site Services program funded transportation to services such as radiation oncology and renal dialysis that were not available in local nursing homes. Table 4 summarizes use of these services.

Table 4. Long-term Care, Subacute, and Transitional Program Utilization, Syracuse Hospitals, 2003-2008

Variable  Volume Patient-days Avoided, 2008
2003 2004 2005 2006 2007 2008
Intravenous medications (n)[a] 45 72 97 60 65 54 756
Oral and subcutaneous medications (n)[a] - 65 73 134 101 77 539
Enhanced medications (n)[a] - - - - 18 22 264
Extensive wound care (n)[a] - - 21 18 16 9 189
Bariatric care (d) - - - - - 132 264
Off-site services (d) - - - - - 158 369

[a]Data are number of patients.
Data obtained from Hospital Executive Council.

 

Table 4 demonstrates that utilization of each of the programs increased to modest levels between 2002 and 2008. Use of the Intravenous Medications and Oral Medications Programs declined in 2008 with the implementation of the Enhanced Medications Program, which addressed some of the drugs contained in these initiatives. The data suggested that these programs were improving the care and the movement of patients in the system by addressing limited but important continuing care needs.

The data also demonstrated that 2381 patient-days were avoided in the Syracuse hospitals through the subacute and transitional programs in 2008. Through the relationships between hospitals and nursing homes that developed through these programs, it is probable that additional patient-days have also been saved.

Results

Overall inpatient days. The implementation of the System Efficiency Program, as well as the Subacute and Transitional Programs, resulted in substantial reductions in hospital stay for patients discharged to nursing homes in the combined Syracuse hospitals. This information is summarized in Table 5.

Table 5. Inpatient Medical/Surgical Mean Length of Stay by Discharge Status, Syracuse Hospitals, 2008[a]

Discharge Status Discharges (n) Mean Length of Stay (d) Severity-Adjusted National Experience Length-of-Stay Difference Patient-days Difference
Self-care 24,973 3.5 3.9 -0.4 -9989.2
Home care 10,962 6.4 5.6 0.8 8769.6
Nursing home 8046 8.6 6.3 2.3 18,505.8
Deaths/transfers 3829 9.2 8.4 0.8 3063.2
   Total 47,810 5.5 5.1 0.4 19,124.0

[a]Data exclude rehabilitation.
Data obtained from Community General Hospital, Crouse Hospital, St. Joseph's Hospital Health Center, and University Hospital - State University of New York Upstate Medical University; National Hospital Discharge Study.

Table 5 identifies mean inpatient stays for adult medicine and adult surgery patients by discharge status for the Syracuse hospitals in 2008. When compared with the data in Table 2, these findings demonstrate that the mean length of stay for patients discharged to nursing homes declined from 11.1 to 8.6 days between 2002 and 2008, a reduction of 2.5 days. During the same period, the differences between the combined hospital stay and the severity-adjusted benchmark declined from 4.4 to 2.3 days. As a result, excess patient-days declined from 25,216.4 to 18,505.8 days, a reduction of 6711 patient-days. This translates into a reduction in average daily census of 18.4 patients.

The shorter lengths of stay for patients discharged to nursing homes were not associated with higher hospital readmission rates. Rates of hospital readmission from nursing homes in the Syracuse metropolitan area have averaged 12% to 14%, considerably below the severity-adjusted national average of at least 20%. The fact that hospital stays for this population (8-11 days) are longer than stays for most medical/surgical inpatients also tends to reduce the incidence of readmissions.

Of note, the reduction in length of stay for patients discharged to nursing homes in Syracuse occurred without the addition of beds to the local long-term care system. The only change in nursing home bed capacity that occurred during this period was the elimination of 50 beds, or 1.6% of system capacity during 2008.

Mental illnesses and ventilator care. Although these data demonstrated considerable progress in the improvement of care for patients discharged from hospitals to nursing homes in Syracuse, many opportunities for additional improvements remain. These opportunities involve hospital stays for populations that have not been affected by the System Efficiency Program at the general level or the specific Subacute and Transitional Care Programs. Table 6 summarizes length-of-stay data for hospital patients with behavioral and mental health diagnoses and patients requiring ventilator assistance.

Table 6. Inpatient Mean Length of Stay, Syracuse Hospitals

 Variable Discharges (n) Mean Length of Stay (d) Severity-Adjusted National Experience Length-of-Stay Difference Patient-days Difference
Mental health as principal diagnosis (APR DRGs 740-776)[a]
   2002 3518 8.9 6.7 2.2 7739.6
   2008 3727 8.4 6.7 1.7 6335.9
Mental health as secondary diagnosis (ICD-9 codes 290.00-319.99)[a]
   2002 15,682 6.9 5.5 1.4 21,954.8
   2008 20,989 5.5 5.1 0.4 8395.6
Ventilator and tracheotomy as APR DRG (APR DRGs 004, 005, and 130)
   2002 390 44.6 28.8 15.8 6162.0
   2008 337 40.1 26.7 13.4 4515.8

APR RG = All Patients Refined Diagnosis Related Group; ICD-9 = International Classification of Diseases, 9th revision
[a]Mental health data include psychiatric and alcohol/substance abuse diagnoses.
Data obtained from New York Statewide Planning and Research Cooperative System (2002 data); Community General Hospital, Crouse Hospital, St. Joseph's Hospital Health Center, and University Hospital - State University of New York Upstate Medical University (2008 data); National Hospital Discharge Study.

 

Data for mental health patients demonstrate that limited progress in the reduction of length of stay in Syracuse hospitals occurred between 2002 and 2008. Most of the progress involved patients with mental illnesses as secondary diagnoses, where the mean stay declined from 6.9 to 5.5 days (20.2%). This reduced the difference between hospital lengths of stay and severity-adjusted national benchmarks from 1.4 to 0.4 days, and excess days for this population from 21,954.8 to 8395.6.days. Because the clinical needs of patients with secondary diagnoses of mental illness frequently overlap those of adult medicine and surgery patients, the impact of length-of-stay reduction for this population was reflected in data for those services.

Less progress was seen in reducing hospital stay for patients with mental illnesses as principal diagnoses. Between 2002 and 2008, the mean length of stay for this population declined by only 0.5 day. As a result, the difference in mean length of stay for the combined hospitals and the severity-adjusted national benchmark declined from 2.2 to 1.7 days, and the number of excess days declined from 7739.6 to 6335.9 days. These modest reductions suggest that most of the length-of-stay problem for this population has not resolved. The 6335.9 excess days amounted to an average daily census of 17.4 for this population alone.

Efforts by the care management directors to reduce lengths of stay for inpatients with mental health diagnoses in the Syracuse hospitals have met with only limited success during the past several years. Much of the problem results from the clinical issues involving the chronic nature of these illnesses, especially psychiatric and substance disorders and the tendency of these patients to consume large amounts of staff time in long-term care facilities. The fact that, whatever clinical initiatives are devised, the healthcare system of the Syracuse metropolitan area contains only 130 long-term psychiatric beds effectively dictates that many of these patients with long-term institutional care needs must be admitted to nursing homes.

During 2005, a planning group involving nursing care management directors and local nursing homes attempted to address the problem of length-of-stay reduction for patients with mental health diagnoses. The directors and their psychiatry nursing staff developed a proposal for a community-wide geriatric team, funded by the hospitals, to support the provision of care to patients with mental health diagnoses in nursing homes.

The proposal failed because nursing home staff could not provide assurances that they would admit additional hospital patients from this population. Nursing homes were concerned that the admission of these patients would generate care needs that could not be addressed by their existing staff members, especially during evening and weekend hours.

Although they participated in the planning process, nursing homes were not confident that the proposed long-term care geriatric team for mental illness could sufficiently address the problem. The need to reduce hospital lengths of stay in order to admit more patients with mental health diagnoses and the lack of sufficient mental health beds in the system suggest that further initiatives must be developed in the near future.

Table 6 also describes the recent experience in the Syracuse hospitals with respect to length-of-stay reduction for inpatients requiring ventilator assistance. Between 2002 and 2008, the mean length of stay for this population declined from 44.6 to 40.1 days, a reduction of 10%. As a result, the difference between the mean hospital stay and the severity-adjusted national benchmark fell from 15.8 to 13.4 days and the annual number of excess days fell from 6162 to 4515.8. The remaining number of excess days amounted to an average daily census of 12.4 for this population alone.

Historically, the efforts of the care management directors to reduce lengths of stay for patients requiring ventilator care have been impeded by the lack of a long-term ventilator program in the community. This circumstance has benefited the community by encouraging the development of clinical programs in hospitals to wean patients from ventilators during their acute care stays. It has also encouraged the development of a medical staff sharing agreement with one long-term care ventilator program in a neighboring county. At the same time, these efforts have left a residual of over 4500 days for this population in area hospitals. A combination of additional hospital programs and joint ventures with other services will probably be required to address this residual.

Reimbursement and family issues. Beyond specific issues such as mental illness, diagnoses, and ventilator care, wider issues that influence hospital length of stay for patients discharged to nursing homes have been identified in the Syracuse metropolitan area. Experience in that area suggests that these concerns are not easily defined and less easily addressed than specific clinical needs.

Reimbursement transition from acute to long-term care services continues to be a major issue. Because hospital stays for elderly patients are typically reimbursed through Medicare, eligibility for the Medicaid program is not usually a concern for patients and families. The onset of chronic illness changes this situation. In New York, the Medicaid eligibility process is lengthy, and its complexity often prompts families to retain attorneys to gather needed documents and address the numerous regulatory requirements. For a typical hospital patient and family, the eligibility process can take 6-12 months to complete. In the meantime, nursing homes are often unwilling to admit the patient because of the lack of a secure long-term care payor.

During the past several years, the care management directors of the Syracuse hospitals have made progress in reducing hospital lengths of stay for patients who require nursing home placement and who have reimbursement issues. They have exhausted legal limits in making patient financial information available to nursing homes. Relatively small numbers of patients with legal issues (such as the establishment of guardianships) continue to generate extended stays in the Syracuse hospitals. Further resource constraints may make it necessary for the hospital care management departments and their administrations to address these problems in the future.

Family concerns are another source of length-of-stay issues for patients who are to be discharged to nursing homes. In the past, such issues have required hospital care managers to devote extensive amounts of time to a small number of patients. As in the case of legal issues, quantitative definition of this problem is elusive; however, anecdotally, care managers have identified a number of examples. Typically, these involve family members who have difficulty comprehending situations involving elderly relatives or in making decisions about them. Some concerns involve family resources, and others involve arguments among family members. Hospital care managers and nursing home admissions staff have attempted to address these issues. Special interpersonal skills and sufficient investment of time are required to resolve these caregiving issues. This must be addressed as the planning process involving family concerns evolves.

Discussion

This study described a series of community-wide efforts to improve the movement of patients from hospitals to nursing homes in the metropolitan area of Syracuse, New York. In recent years, this area has experienced increases in elderly populations and reductions in younger age groups. These social changes are leaving the acute hospitals with a residual of sicker patients whose care must be addressed for their own sake and to support throughput in the entire area's healthcare system. In an environment marked by increasing constraints on resources for hospitals and other healthcare providers, the need to improve efficiency by reducing hospital stays for this population has become paramount.

Improving the movement of patients between hospitals and nursing homes requires attention to both clinical and administrative issues. Typically, the clinical needs of these patients are considerable because of multiple diagnoses that must be managed between acute care and long-term care settings. The ability to evaluate these patients according to severity of illness provides useful support for the clinical management process. The administrative implications of this process are closely related to the clinical issues. They require the participants to address staffing, reimbursement, and regulatory issues beyond individual provider organizations within a community healthcare environment.

The example of Syracuse suggests a challenging view of the future for many community healthcare systems elsewhere in the nation. In these metropolitan areas, the departure of increasing numbers of young people and older adults with resources leaves a disproportionate number of patients with major clinical and social needs. Addressing these needs requires large amounts of nursing and financial resources. For hospitals with declining younger populations and the resources they generate, this can be a real problem.

This study demonstrated that the Syracuse hospitals were able to reduce mean lengths of stay by 2.5 days and improve patient care for patients discharged to nursing homes between 2002 and 2008, saving over 6711 acute care days. This reduction was achieved through a good amount of nursing creativity with a modest admixture of funding. Hospital nursing care managers accomplished these improvements through relatively simple mechanisms, such as the distribution of data about DTP patients and supporting activities, hospital efforts to refer attractive patients to nursing homes, and the implementation of subacute and transitional care programs for patients requiring specific services (eg, intravenous medications, high-cost oral medications, extensive wound care, and bariatric care).

Hospital advanced practice nurses (APNs) were extensively involved, with care managers and inpatient nurse managers, in the development of these programs at the clinical and administrative levels. The clinical input of these APNs was important in the support of patient care. Because the population of patients discharged from hospitals to nursing homes has multiple acute and chronic diagnoses, the capabilities of APNs were important to the management of this group. APN leadership was also essential to the development of the administrative processes that were necessary to support the movement of patients between acute care and long-term care.

Some of the important issues relating to the movement of patients from hospitals to nursing homes in Syracuse are still being addressed. One of the most important of these is length-of-stay reduction for patients with mental illnesses because of the large amounts of staff time consumed by these patients in long- term care facilities and because of the long lengths of stay produced by these patients in nursing homes. The difficulties of addressing this population were illustrated by the efforts of the Syracuse hospitals to develop a community-wide psychogeriatric team in 2005. In this instance, the planning was successful, but the results were not.

Remaining concerns also involved purely social issues. In this area, the Syracuse hospitals have made progress through exchange of financial information with nursing homes; however, the challenges of guardianships and other special situations remain. Family difficulties have also resisted solutions, particularly when patients experience medical crises and relatives have limited time to make decisions concerning post-acute care services.

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