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Reducing avoidable rehospitalizations among seniors
Date:6/12/2011

ssion can lead to a steady decline in functional status, ending in disability. As a result, these seniors must often trade their independent living for a long-term care facility.

As part of national health-care reform legislation, Medicare will stop paying hospitals for preventable readmissions for conditions such as heart failure and pneumonia, beginning in October 2012. Two years later, the list will expand to include additional medical conditions.

"Reducing rehospitalization has become a national target of health-care reform," says Robert J. Schreiber, M.D., HSL's chief medical officer. "Readmissions have a significant impact on the nation's health system and are often preventable."

Developed by HSL's Department of Medicine and key nursing, administrative and social service leaders, the admission template includes care guidelines for common geriatric syndromes, medication reconciliation, and goals of care, as well as a question about how many times the patient had been hospitalized over the past six months. A section on advance directives asks whether the patient or health-care proxy would want subsequent hospitalizations if the patient's condition deteriorated while on the SNF.

HRC's palliative care team consulted with patients who had three or more hospitalizations in the past six months to determine whether rehospitalization was consistent with the patient's goals of care, or if worsening symptoms would be managed best on a SNF, in long-term care, or at home.

Team Improvement for the Patient and Safety (TIPS) conferences were held bimonthly to examine the root causes of rehospitalizations. Selected cases of preventable rehospitalizations were reviewed to identify ways in which the team could have operated more effectively. Depending on the specific causes identified, further information would be sought and additional staff or outside experts would be invited to participate in subsequent TIPS sessions.

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Contact: Scott Edwards
Edwards@hsl.harvard.edu
617-363-8309
Hebrew SeniorLife Institute for Aging Research
Source:Eurekalert

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