December 11, 2017, Maggie Flynn, Skilled Nursing News - If a nursing home wants fewer hospitalizations, it needs more nursing personnel. This was the takeaway from a report released in October on an initiative supported by the Centers for Medicare & Medicaid Services (CMS).
The initiative was meant to reduce avoidable hospitalizations among nursing facility residents, and was part of the Missouri Quality Initiative for Nursing Homes (MOQI).
Indiana had a similar program, and the Hoosier State also found embedding nurses and nurse practitioners could significantly reduce potentially avoidable hospitalizations through its OPTIMISTIC program. Both the Missouri and Indiana programs were supported by CMS.
“It’s not just the cost of the stay,” Dr. Marilyn Rantz of the University of Missouri, who led the Missouri program, told Skilled Nursing News. “What it’s really about is avoiding that disability that comes with the acute experience.”
The Missouri program had 17 advanced practice registered nurses (APRN) working full time at 16 nursing facilities. There was one for each facility, with the exception of one larger facility that had two APRNs. One of those two would “float” to other facilities as needed.
The Missouri initiative reduced hospitalizations from all causes by 33% and potentially avoidable hospitalizations by 48%, with total Medicare expenses cut by $1,376 per person. This saved 33% of the costs of all-cause hospitalizations and 40% of potentially avoidable hospitalizations, the report found.
Phase II of the study involves being able to provide more treatment within the nursing facility, Rantz said, and there are 40 nursing facilities — including the original 16 — that are taking part in this phase. CMS established a payment plan for this phase that provides additional daily fees for acute treatment, she explained, with the aim of testing whether this further reduces hospitalizations.
“I think that there are possibilities in the future for additional acute care payment to treat people within the nursing home, but we won’t know these results for another couple of years,” she noted.
Early detection of such health issues as pneumonia and urinary tract infections is crucial for avoiding the issues that come with an acute care stay. This is why the presence of an APRN is so important, Rantz explained.
“What the APRN does is improve early illness recognition and improve staff recognition skills,” she said. “Doing that then avoids the hospitalization and the person then avoids the increased functional decline.”
The study paid for the full salaries of the APRNs in the initiative, but some nursing providers might balk at the possible cost of hiring APRNs for every facility. However, this isn’t necessarily a problem, said Rantz, who worked as a nursing home administrator in Walworth County in Wisconsin from 1981 to 1992.
“It was possible to build the APRNs into the staffing pattern, and it worked fine,” she said of her time there. “Yes, they are more expensive than RNs, but to the residents and to the families the outcome benefits were worth it, and I could justify that in the budget and got that through my board.”
The benefits of having APRNs also include improvements in quality measures and reduced hospitalizations, so the facility gains from their presence, Rantz said.
She also doesn’t buy labor shortage as an excuse.
“The whole issue with RNs is that if you create a good environment, they will come and work for you,” she said, echoing what other experts have told SNN.
If APRNs could work in each of Missouri’s 500 nursing homes, Medicare costs for the more than 39,000 nursing home residents would be reduced by about $53.9 million a year based on the findings, Rantz estimated in the release. But bringing that to reality will be a challenge; Missouri regulates APRNs more tightly than any other state, she told SNN.
“It’s time for nursing homes to have access to APRNs, and it’s time for primary care clinics all over the state to have access to them,” she said. “And we currently have some very onerous regulations that are not necessary and are not grounded in research.”
Legislation has been proposed in Missouri to reduce some of those regulations, while the MOQI is preparing materials for getting APRNs in nursing facilities across the state, Rantz said. In the meantime, she and her colleagues published a “call to action” in Nursing Outlook that detailed the billing restrictions for APRNs working in long-term care facilities and what regulations could be improved to boost access to care by APRNs.
And though “there are a lot of political variables” in rolling out a program to get APRNs into every U.S. nursing facility, Rantz believes it could be done.
“I think it’s feasible for some states to implement it sooner than others because of their advanced practice regulations, or lack thereof,” she said.