Medicare Takes Aim At Boomerang Hospitalizations Of Nursing Home Patients

“Oh my God, we dropped her!” Sandra Snipes said she heard the nursing home aides yell as she fell to the floor. She landed on her behalf right side where her hip had been recently replaced.

She cried out in pain. A medical facility clinician later discovered her hip was dislocated.

That wasn't the only real injury Snipes, then 61, said she suffered in 2011 at Richmond Pines Healthcare & Rehabilitation Center in Hamlet, N.C. Nurses allegedly had been injecting her twice daily with a potent blood thinner despite written instructions to prevent.

“She said, 'I just feel so tired,'” her daughter, Laura Clark, said within an interview. “The nurses were saying she's depressed and wasn't doing her exercises. I said no, something is wrong.”

Her children also learned that Snipes' surgical wound became infected and infested with insects. Just 11 days after she reached the nursing home to heal from her hip surgery, she was during the hospital.

The fall and these other alleged lapses in care led Clark and also the family to file a lawsuit from the elderly care. Richmond Pines declined to discuss the situation beyond saying it disputed the allegations at that time. The home agreed in 2021 to pay Snipes' family $1.4 million to settle their lawsuit.

While the confluence of complications in Snipes' case was extreme, return trips from nursing homes to hospitals are not even close to unusual.

With hospitals pushing patients out of the door earlier, nursing facilities are deluged with increasingly frail patients. However, many homes, using their sometimes-skeletal medical staffing, often neglect to handle post-hospital complications – or create new problems by not heeding or receiving accurate hospital and physician instructions.

Patients, caught in the centre, are affected. One in 5 Medicare patients sent in the hospital to some nursing home boomerang back within Thirty days, often for potentially preventable conditions for example dehydration, infections and medicine errors, federal records show. Such rehospitalizations occur 27 % more frequently than for that Medicare population in particular.

Nursing homes have been unintentionally rewarded by decades of colliding government payment policies, which gave both hospitals and nursing facilities financial incentives for the transfers. Which has left probably the most vulnerable patients often ping-ponging between institutions, wreaking havoc with patients' care.

“There's this saying in nursing homes, and it is unfortunate: 'When in doubt, ship them out,'” said David Grabowski, a professor of healthcare policy at Harvard School of medicine. “It's a short-run, cost-minimizing strategy, however it ends up costing the system and the individual much more.”

In recent years, the federal government has begun to tackle the issue. In 2021, Medicare began fining hospitals for top readmission rates in an attempt to curtail premature discharges and also to encourage hospitals to touch on patients to nursing facilities with good records.

Starting this October, the federal government will address sleep issues from the equation, giving nursing homes bonuses or penalties based on their Medicare rehospitalization rates. The aim is to accelerate early indications of progress: The rate of potentially avoidable readmissions dropped to 10.8 percent in 2021 from 12.4 percent this year, according to Congress' Medicare Payment Advisory Commission.

“We're better, although not well,” Grabowski said. “There's still maximum inappropriate readmissions.”

The revolving door is definitely an unintended byproduct of long-standing payment policies. Medicare pays hospitals a set rate to look after someone with respect to the average time it takes to deal with a patient with a given diagnosis. This means that hospitals effectively profit by earlier discharge and lose money by keeping patients longer, despite the fact that a senior patient may require a few extra days.

But nursing homes need to hospitalize patients. To begin with, keeping patients out of hospitals requires frequent examinations and speedy laboratory tests – all of which add costs to nursing homes.

Plus, most elderly care residents are covered by Medicaid, the state-federal program for the poor that is normally the lowest-paying form of insurance. If your elderly care sends a Medicaid resident to the hospital, she usually returns with up to 100 days covered by Medicare, which pays more. On top of everything, in some states, Medicaid pays a “bed-hold” fee whenever a patient is hospitalized.

None of this will work for the patients. Nursing home residents often return in the hospital more confused or with a brand new infection, said Dr. David Gifford, a senior vice president of quality and regulatory affairs in the American Healthcare Association, a nursing home trade group.

“And they never quite return to normal,” he explained.

'She Looked Like A Wet Washcloth'

Communication lapses between physicians and nursing homes is one recurring reason for rehospitalizations. Elaine Essa have been taking thyroid medication ever since that gland was removed when she would be a teenager. Essa, 82, was living at a nursing home in Lancaster, Calif., in 2021 whenever a bout of pneumonia sent her towards the hospital.

When she returned to the elderly care – now named Wellsprings Post-Acute Care Center – her doctor omitted a crucial instruction from her admission order: to resume a thyroid problem medication, according to a case filed by her family. The elderly care telephoned Essa's doctor to order the medication, but he never called it well, the suit said.

Deborah Ann Favorite holds a photograph of her mother, Elaine Essa. The nursing home and Essa's primary care practice settled a lawsuit brought by the household. (Heidi de Marco/KHN)

Without the medication, Essa's appetite diminished, her weight increased and her energy vanished – all warning signs of a thyroid imbalance, said the family's attorney, Ben Yeroushalmi, discussing the lawsuit. Her doctors from Garrison Family Medical Group never visited her, sending instead their nurse practitioner. He, like the nursing home employees, didn't hold the reason for her decline, although her thyroid condition was prominently noted in her medical records, the lawsuit said.

Three months after her return in the hospital, “she appeared as if a wet washcloth. She had no color in her face,” said Donna Jo Duncan, a daughter, inside a deposition. Duncan said she demanded the home's nurses check her mother's blood pressure level. When they did, a supervisor ran over and said, “Call an ambulance right away,” Duncan said within the deposition.

At a healthcare facility, a physician said tests showed “zero” thyroid hormonal levels, Deborah Ann Favorite, a daughter, recalled within an interview. She testified in her deposition the doctor told her, “I can't think that this woman continues to be alive.”

Essa died the following month. The elderly care and also the medical practice settled the situation for confidential amounts. Cynthia Schein, a lawyer for that home, declined to go over the situation beyond saying it was “settled to everyone's satisfaction.” The suit continues to be ongoing against one other doctor, who didn't respond to requests for comment.

Dangers In Discouraging Hospitalization

Out from the nation's 15,630 nursing facilities, one-fifth send 25 % or more of their patients back to a healthcare facility, according to a Kaiser Health News analysis of data on Medicare's Nursing Home Compare website. On the other end of the spectrum, the fifth of homes with the lowest readmission rates return less than 17 percent of residents to the hospital.

Download the information to see how skilled nursing homes in the U.S. performed on two metrics of quality.

Many health policy professionals state that spread shows just how much improvement can be done. But patient advocates fear the campaign against hospitalizing nursing home patients may backfire, especially when Medicare begins linking readmission rates to the payments.

“We're always worried unhealthy nursing facilities are going to get the message 'Don't send one to a healthcare facility,'” said Tony Chicotel, a staff attorney at California Advocates for Nursing Home Reform, a nonprofit located in Bay area.

Richmond Pines, where Sandra Snipes stayed, has a higher-than-average rehospitalization rate of 25 %, according to federal records. But the family's lawyer, Kyle Nutt, said the lawsuit claimed the nurses initially resisted sending Snipes back, insisting she was “just drowsy.”

After Snipes was rehospitalized, her blood thinner was discontinued, her hip was reset, and she or he was discharged to a different elderly care, according to the family’s lawsuit. But her hospital trips were not over: When she showed indications of recurrent infection, the second home sent her to another hospital, the lawsuit alleged.

Ultimately, the lawsuit claimed that doctors removed her prosthetic hip and most a liter of infected blood clots and tissues. Nutt said if Richmond Pines' nurses had “caught the over-administration of the blood thinner right off the bat, we don't think any of this would have happened.”

Snipes returned home but never was able to walk again, according to the lawsuit. Her husband, William, cared for her until she died in 2021, her daughter, Clark, said.

“She didn't want to return into the nursing home,” Clark said. “She was terrified.”