Here is a common scenario in U.S. nursing homes:

A 90-year-old resident with moderately advanced Alzheimer’s disease, congestive heart failure with severe left-ventricular dysfunction and chronic pain from degenerative joint disease develops a nonproductive cough and a fever of 100.4 degrees.

The night nurse calls the on-call physician who is unfamiliar with the patient and is instructed to send the patient to the emergency room. In the ER, the patient is found to have normal vital signs except for the low-grade fever and a possible infiltrate on the chest x-ray.

The patient is admitted to the hospital and treated with intravenous fluids and antibiotics. On the second night, the patient becomes confused and agitated, climbs out of bed and falls, fracturing a hip. One week later, the patient is discharged back to the nursing home with coverage under the Medicare Part A benefit. This episode results in approximately $ 10,000 in Medicare expenditures, and discomfort and disability for the patient.

There are more than 1.6 million Americans living in nursing homes, and these types of hospitalizations are common. Hospitalizations of frail nursing home residents can result in higher costs, complications and death. The “Revolving Door of Rehospitalization from Skilled Nursing Facilities,” a paper published in the January 2010 issue of Health Affairs, 23.5 percent of Medicare beneficiaries discharged from the hospital to a skilled nursing facility were readmitted to the hospital within 30 days at a cost to Medicare of $ 4.34 billion in 2006. These rehospitalizations are frequent and costly. Research suggests that a substantial amount of these hospitalizations can be prevented.

There is an alternative to this scenario in the current issue of The New England Journal of Medicine. By using a standardized protocol and working with an on-call nurse practitioner who visits the nursing home daily, the patient can be treated in the nursing home without any complications and only costing Medicare about $ 200.” – Joseph G. Ouslander, M.D., senior associate dean of geriatrics

Using such care in nursing homes nationwide could improve care, reduce complications from hospitalizations, and avoid hundreds of millions of dollars in Medicare expenditures annually.

Ouslander and his co-author Robert A. Berenson, M.D., senior fellow at the Urban Institute in Washington, D.C., explain that although many nursing home residents could be cared for safely and effectively without being admitted to the hospital, the causes for preventable hospitalizations in this population are complex.

They explain that one of the fundamental problems with hospitalizations of this population is not clinical. Rather, it is financial and stems from a misalignment of Medicare and Medicaid. State Medicaid programs do not benefit from savings that Medicare accrues from prevented hospitalizations of nursing home residents, even though the nursing home incurs expenses when managing changes in condition without hospital transfer.

The authors also point out that not all nursing homes have the infrastructure to undertake more acute care, and it is imperative to recognize challenges and limitations. For example, because of financial constraints and shortage of health care professionals trained in geriatrics and long-term care, not all nursing homes have the capacity to safely evaluate and manage changes in the condition of the clinically complex nursing home population. Interventions must therefore be designed for nursing homes with the resources and leadership commitment to undertake more acute care.

In conclusion, the authors emphasize that improving care and reducing complications in nursing homes will require multifaceted strategies to address the current incentives for hospitalization and a team effort among health care funders, regulators, health care professionals, nursing homes and hospitals.