Earlier this summer, health care professionals from all over San Diego County met to learn about current trends in post-acute care and hospital readmission efforts.  Hosted by Health Services Advisory Group under the guidance of Debra Nixon and her colleagues, and with local assistance from CALTCM board members Parag Agnihotri, MD, CMD and Karl Steinberg, MD, CMD, HMDC, this half-day collaborative event drew about 150 attendees.  

The meeting kicked off with review of San Diego County 30-day rehospitalization data, indicating a slight improvement in the past year or so—and an average level around 18% that is better than statewide and national averages.  Dr. Joel Sorboro, an addiction specialist, followed with the opening keynote on the topic of opioids, reviewing data on opioid deaths and strategies, including Medication-Assisted Treatment (using buprenorphine [e.g., Suboxone] or methadone), and reviewing some of the regulatory and commercial efforts to reduce excessive opioid prescribing.  

Dr. Steinberg then reviewed initiatives around reducing inappropriate POLST usage in nursing homes. As a member of the National POLST Paradigm’s Leadership Council, he reminded the audience that POLST is never mandatory, should not be used as a code status document for all nursing home residents, and is meant for patients who are nearing the end of life.  If a patient wants “usual” care, meaning CPR in the event of a cardiac arrest, there is no reason to create a POLST form since that is what our default treatment is for everyone—except for the small segment of the population who truly wants their life prolonged to the last possible instant. Dr. Steinberg reminded attendees that POLST is not just a check-box form, but should reflect a deep and substantive conversation between the physician (or other health care professional) and the patient/family.  He recommended using another type of documentation as the default code status form in nursing homes (such as a preferred intensity of treatment or preferred intensity of care [PIT/PIC] form, and offering POLST only to patients who are seriously, chronically ill and within a year or two of life or who have strong feelings about the kind of end-of-life care they will receive—especially those who do not want CPR.  

Section S of the revised MDS form that will be in place in October will include this reminder:  

”Note: Physician Orders for Life-Sustaining Treatments (POLST) is only appropriate for patients who are seriously ill or nearing end of life. POLST is never mandatory and should not be required as a condition to admission.”

Next, Dr. Zia Agha of West Health Foundation spoke about an initiative to create geriatric emergency departments, and a pilot that is active at UCSD.  The benefits of such specialized care should be clear to our members and WAVE readers, in that usual care in an emergency department often results in inaccurate diagnoses (e.g., dehydration or UTI), inappropriate treatments (e.g., unnecessary antibiotics, anticholinergics, antipsychotics, benzodiazepines, etc.)  Having physicians, social workers and nurses who are familiar with geriatric syndromes and the metabolic and other special factors in this population can clearly minimize adverse outcomes, of the kinds we see frequently when long-term care (and to a lesser degree, post-acute) nursing home residents are subjected to an emergency room visit.   Delirium and restraints associated with bladder and intravenous catheterization, unfamiliar surroundings and general bewilderment are common when frail nursing home residents are moved from their homes—and the presence of geriatric-sensitive providers should help reduce those complications.

Myron Soyanco, a quality improvement specialist from SHARP Healthcare, then detailed some of the interventions they have used with their Extended Care team to reduce readmissions. The data were compelling, with very robust reductions in 30-day rehospitalizations after the interventions were implemented.  Communication and early identification of changes of condition were key factors in producing these impressive results.  

Dr. Jamie McKinnell, an infectious disease specialist from USC, then shared insights about how an effective antibiotic stewardship program should be implemented in nursing homes—including involvement of an engaged and knowledgeable physician.  If the facility medical director does not fulfill that role and is unable to step into it, Dr. McKinnell recommended considering looking elsewhere. He reviewed changes to recommended antibiotic durations (shorter) and indications (more stringent), but suggested not being overly restrictive with criteria—especially the McGeer criteria.  Dr. McKinnell favored the use of the Loeb criteria for antibiotic use. One sample letter to attending clinicians from the Agency for Health Care Research and Quality (AHRQ) that includes these criteria can be found at this site: http://bit.ly/ahrq-loeb.  Dr. McKinnell also strongly cautioned prescribers against using quinolones (e.g., levofloxacin [Levaquin] and ciprofloxacin [Cipro]) except in unusual circumstances, for a variety of reasons including multiple serious adverse effects with boxed warnings (aneurysms, tendon rupture, C.diff., QTc prolongation) and high levels of quinolone resistance in the nursing home flora, at least in Southern California.  

Dr. Chris Mlot, a past CALTCM president now working as a medical director for VITAS Hospice, presented on the lessons learned in her many years of nursing home medical direction and attending physician duties, referring to herself as a “recovering SNFologist” in the title of her presentation.  Dr. Mlot shared insights into the changes we have seen since the 1990s in skilled nursing facilities, some good and some not so great. Some of the controversies around rehospitalization penalties were discussed. Dr. Mlot also observed that the upcoming nursing home post-acute reimbursement changes with PDPM (the patient-driven payment model) will give an opportunity for additional growth.

Finishing off the educational content was Dr. Rebecca Ferrini, a CALTCM leader and popular speaker at our meetings, discussing how root cause analysis can help solve problems and be used as part of the QAPI (Quality Assurance/Process Improvement) function in skilled nursing facilities, using real-life examples and creative problem-solving.

At the end of the sessions, awards were given to the three nursing homes in San Diego County that HSAG determined had enjoyed the most success in reducing their 30-day rehospitalization rates by participating in the statewide HSAG program designed to help nursing facilities reduce readmissions.  These facilities were Encinitas Nursing and Rehabilitation Center, Point Loma Post-Acute Center, and Escondido Post-Acute Rehab. CALTCM salutes these facilities, and HSAG, for their excellent efforts in reducing unnecessary hospital trips for their residents.