With the state's financial blessing, 49 of Minnesota's 384 nursing homes are launching a three-year pilot program that could save millions of dollars by sharply reducing the number of times sick or failing residents are sent to a hospital.
The project will give nursing home staff a set of tools to assess patients and reconsider before sending them to hospital emergency care for common conditions such as dehydration, fevers and infections, as well as disease end-stages that might best be treated with palliative care.
The concept, which has been proved in smaller tests, could cut avoidable hospitalizations by up to 20 percent, planners say.
"Both the move to a hospital and actually being there are dangerous for frail people," said Dr. Robert Kane, a University of Minnesota aging expert who is helping lead the experiment. Hospitalization can leave elderly patients vulnerable to infections, falls and a form of short-term dementia that results from an abrupt change of setting. "We may actually save lives and save money," Kane said.
It's a major concern for elderly patients and those who pay the bills for their care. Nationally, some 240,000 nursing home-hospital trips may be avoidable annually, said Dr. Joseph Ouslander a Florida Atlantic University researcher who developed the program, called Interact. That's a yearly cost of $3.1 billion.
The effort comes as Minnesota hospitals have started their own effort to reduce expensive re-hospitalizations. They hope to cut the number by 4,000 this year and save $30 million, spurred in part by a state initiative to reward hospitals that succeed.
Nursing homes in the Interact project will share $10.2 million if they meet their goals. Previous Interact projects have found a savings of about $16 for each dollar invested.
"We're not out to stop all hospital re-admissions," Ouslander said at training last week for the participating nursing homes. "We're aiming for the right care in the right place. Those who need hospital care should get it quicker."
'Stop and Watch'
At Augustana Care Center in Minneapolis, nursing aide Jeff Robinson has been trained in the first line of defense, a checklist called "Stop and Watch."
It's designed to help front-line staff pay close attention when they see changes in the residents they tend daily.
"You're more alert," Robinson said, flicking a finger against the half-page sheet. "Someone is talking or eating less, or they seem tired or upset or unsteady. Those are signs to watch for and tell the nurse about."
While most of the nursing homes in the project have just begun staff training, Augustana has been using Interact for a year.
Spotting subtle changes is helping the staff catch problems earlier, said Pamela Hayle, the home's quality improvement director. That could avert a medical crisis requiring hospital care -- or speed a trip to the emergency room, she said.
Nurse Celeste Singh gets some of those early-warning reports from aides. If the resident seems in serious trouble, she'll call the doctor -- but first she'll use another checklist for a deeper assessment so she can better answer the doctor's questions.
"It helps me focus," she said. "What precisely is the problem? When did it start? Has this occurred before? What are her vitals, and what does her advance directive say about the care she wants?"
Last week, the process kept an Augustana resident out of the hospital after she struck her head in a fall. Singh told the doctor that the home could X-ray the resident, helping the doctor discover without an emergency room visit that she was not badly hurt.
"That felt good," she said. "We are making a difference for people."
'The problem is the doctors'
Nursing home workers "get it right away," said Ouslander, like Kane a physician and researcher; they met when they taught at UCLA. He said he gets daily calls from nursing homes about Interact.
"The problem is the doctors," he said. Physicians familiar with nursing homes learn quickly to trust the precise information from nurses using the Interact tools. "But for the others, especially nights or weekends, the default is hospitalization."
One reason some states and nursing homes have been slow to invest in programs like Interact is that the bulk of the savings goes to the federally funded Medicare program, which covers hospital care, but not to Medicaid, a state-federal program that covers nursing home care for 60 percent of residents.
Medicaid is paying for this project, and expects to reap at least some savings from it.
"Ultimately -- as with all attempts to control health care costs -- we need to figure out how to share the savings with those who make it happen," Ouslander said.
In the end, though, better care, not saving money, is the main goal, officials said.
"Actually, the cost of care for some residents in nursing homes might rise," said Bob Held, director of nursing home rates and policy at the state Department of Human Services, which funds the project. "Healthier people live longer."
"Nursing homes by and large do a good job of caring for residents, who are more medically fragile than in the past," he said. "This is a chance to learn how to do that even better and smarter, and to use our scarce dollars more wisely."
Warren Wolfe • 612-673-7253