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Nursing home intervention does not reduce hospitalizations

Receiving training and support in implementing a quality improvement program to reduce hospital admissions and ED visits from nursing homes demonstrated no effect, according to findings published in JAMA Internal Medicine.

“Policy makers are increasingly focused on the high rate of hospitalizations and ED visits in the nursing home population,” Robert L. Kane, MD, from the University of Minnesota School of Public Health, and colleagues wrote. “Approximately 20% to 25% of [nursing home] admissions are readmitted to the hospital within 30 days. A substantial percentage of these hospitalizations are rated as potentially avoidable. On average, [nursing home] residents are sent to the ED close to twice per year, many with normal vital signs and no diagnostic test, suggesting that these visits were avoidable. These patterns are particularly troubling given that [nursing home] residents are at high risk to develop complications during hospitalization and ED visits.”

Kane and colleagues performed a randomized implementation trial of a quality improvement program called Interventions to Reduce Acute Care Transfers (INTERACT) to determine whether training and support for the program reduced hospital admissions and ED visits. They randomly assigned 85 nursing homes with 36,717 residents that reported no use of INTERACT prior to the study to either the intervention group (n = 33) or control group (n = 52). Nursing homes in the intervention group received training and implementation support on INTERACT, including tools to identify and assess acute changes in nursing home resident conditions and advance care planning and quality improvement. Changes in hospitalization and ED visit rates between the preintervention and postintervention periods were compared among both groups.

Compared with nursing homes in the control group, those in the intervention group showed statistically nonsignificant reductions in hospitalization rates (net difference, 0.13 per 1,000 resident-days), 30-day readmission rates (net change in rate among hospital discharges, 0.01), ED visits without admission (net difference, 0.02 per 1,000 resident-days), hospitalizations during the first 30 days after nursing home admission (net difference, 0.37 per 1,000 resident-days) and hospitalizations more than 30 days after nursing home admission (net difference, 0.09 per 1,000 resident-days). In addition, there was a reduction in hospitalizations considered potentially avoidable among nursing homes in the intervention group; however, this reduction did not remain after Bonferroni correction.

“Training and support for INTERACT implementation as carried out in this study had no effect on hospitalization or ED visit rates in the overall population of residents in the participating [nursing homes],” Kane and colleagues concluded.

“The lack of effects of the training and implementation support for INTERACT in this study may be related to several factors, including the specific nature of the training and implementation support provided, the quality of the [nursing home] staff and medical care, concerns over legal and regulatory liability of attempts to manage sicker patients in the [nursing home], and varying degrees of motivation to reduce hospitalizations, ED visits, and hospital readmissions based on the local penetration of value-based care initiatives such as Medicare-managed care, bundled payments and accountable care organizations,” they added.

A previous study published in JAMA Internal Medicine found that another nursing home training program, OASIS, was associated with a reduction of antipsychotic use. – by Alaina Tedesco

Disclosure: The researchers report receiving support from the National Institute for Nursing Research and Medline Industries.