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End of Regulation

Plan aims to reduce patients’ readmission to hospitals

Staffers at about three dozen Massachusetts nursing homes soon will receive intensive training aimed at reducing the number of residents who cycle back and forth to hospitals, often with preventable health problems.

The federal government has been pressuring hospitals to reduce such repeat admissions, but now it is funding a pilot program to attack the problem from the other side, by improving the care of nursing home residents.

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The one-year program, which its creators hope becomes a national model, will train staff “behavior teams” to decipher the reasons for difficult behavior from residents, many of whom have dementia and are unable to speak. The teams will learn ways to care for residents who are punching, slapping, or screaming, without resorting to physical restraints or antipsychotic medications to sedate them. Both these approaches can cause serious health complications, leading to hospitalization.

“If they are being given antipsychotics or physical restraints, it’s because we are only looking at the symptoms” and not the reason for the behavior, said Rebecca Elkins, project director and patient safety manager at Masspro, a Massachusetts organization that helps federal and state governments improve health care.

Residents may act out because they are in pain from a urinary tract infection but are unable to communicate their discomfort to staff, or are bored and become agitated, increasing the risk of a fall and injury.

“Perhaps there are other things that we can do to prevent falls, or catch that urinary tract infection, and keep them in the home and not send them to the hospital,” Elkins said.

The program, funded by a new $380,000 grant from the federal Centers for Medicare & Medicaid services, will track each nursing home’s rate of readmitting residents to hospitals within 30 days of a hospital discharge, and their use of antipsychotic medications, which are powerful sedatives that can be lethal for elderly patients with dementia. It will also monitor use of physical restraints, the number of times residents fall, have urinary tract infections, or are involved in altercations.

Massachusetts has one of the higher rates of hospital readmissions in the country for all patients, with 16.3 percent ending up back at hospitals within 30 days of discharge, according to a 2010 analysis by the Dartmouth Atlas of Health Care. The national average was 15.9 percent.

Repeat hospitalizations can be traumatic for patients, exposing them to infections and other complications. They are also costly. The Centers for Medicare & Medicaid Services has estimated the cost of avoidable hospital readmissions at more than $17 billion a year.

Paul Raia, vice president for clinical services at the Alzheimer’s Association of Massachusetts and New Hampshire, who will train nursing home staffers for the project, said the behavior teams will include nurses, program and activities directors, and nursing aides, but not physicians. Raia said physicians sometimes are more prone to prescribe antipsychotics for problem patients.

“I want the team to brainstorm to look for behavioral interventions, rather than pharmacological ones,” he said.

“That’s not to say we are going to exclude medications,” Raia said. “It would be inhumane to not give medications to quell their anxiety. But we could introduce modifications that might reduce the dosage.”

The project comes as state and federal regulators are focusing on reducing the use of antipsychotics in nursing homes and the rate of repeat hospitalizations among Medicare patients.

A Boston Globe series last year found that thousands of US nursing home residents received antipsychotic drugs contrary to government recommendations, often to control agitation and combative behavior among those with Alzheimer’s disease or other dementias. It found substantially higher usage rates in Massachusetts, and since then, the state’s nursing home industry has expanded a different pilot program, called Oasis, designed to reduce antipsychotic use at approximately 100 of the state’s 420 facilities.

“We are going to have to saturate our industry with training over a long time to see sustained change,” said Laurie Herndon, director of clinical quality for the Massachusetts Senior Care Foundation, which launched the Oasis program in collaboration with the state Department of Public Health.

Results from the first year of Oasis found that the 11 Massachusetts nursing homes in the pilot lowered rates by 21 percent.

Kay Lazar can be reached at klazar@globe.com.
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