Coming up with an accurate predictive model for rehospitalization rates has been as challenging a task as any for nursing home administrators across the country. Is there a predictive factor? Is it age, gender, race, diagnoses? The question has remained at the top of the conversation starter list throughout the industry.
In late August, McKnight’s Long-Term Care News reported that the answer may have been developed. Citing research conducted at the Regenstrief Institute and Indiana University Center for Aging Research, the best indicator may be in whether or not the nursing home has coordinated systems in place. Kathleen Unroe, MD, a Regenstrief Institute investigator and lead author of the study explained “From the nursing home’s perspective, it should be less about specific disease states, and more about putting in place excellent communication protocols, appropriate clinical staffing, access to diagnostic testing, and robust palliative care programs.”
The study focused on patients with one of the six diagnoses most commonly linked with avoidable hospitalization (pneumonia, UTI, dehydration, pressure ulcers, cellulitis, heart failure and COPD/asthma). Of the acute transfers of patients with these conditions, 45% of the conditions could have been managed safely if appropriate resources had been available. Problems with communication between stakeholders were the most commonly noted area for improvement at about 48% of the time.
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