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What I am seeing in SE PA is some gaming of the system. Medicare clients readmitted within 30 days with minor illness: 2-4 day stay is being placed under observation status rather than admision. Readmission now results in homecare referral (should have had as part of 1st admit discharge planning) with RN visiting next day. Even SNF's are having patients be readmitted within 1st week home if they can't function with caregiver support. This never happened in my area prior 2012-had to go to the hospital first.
Two major health systems in my area closed their SNF's 4 yrs ago as losing monies resulting in patient being placed 30 miles away in different counties due to lack of beds. Now health systems are forming alliances with SNF owners to decrease length of stay and readmit rates and lwith bed closer to home.
Gotta watch this thread.... I see it as more people not being admitted that need it. Longer stays for people that should be home. The main problem I see with this; we as a whole will be punished for chronic non-compliant pts whom don't take responsibility for their own health. Renal pts as an example in the hospital are a revolving door, they are admitted at least monthly for CHF, overload, missing HD and just going to the hospital to get "fixed". How is this the fault of nursing staff or the PCP, we can't turn them away; this will lead to more law suits and now if they are readmitted we are dinged. From my understanding from our managers, it doesn't matter the cause of the readmission. So say someone had a MI 3 weeks ago and was admitted, DC'd home and was in a MVC, we will not get paid for the MVC admission. I really hope this is not true, but I haven't researched it on my own yet. I don't see how this is going to work sadly.
that wouldn't be a REadmission, so should not matter, we shall see.
Gotta watch this thread.... I see it as more people not being admitted that need it. Longer stays for people that should be home. The main problem I see with this; we as a whole will be punished for chronic non-compliant pts whom don't take responsibility for their own health. Renal pts as an example in the hospital are a revolving door, they are admitted at least monthly for CHF, overload, missing HD and just going to the hospital to get "fixed". How is this the fault of nursing staff or the PCP, we can't turn them away; this will lead to more law suits and now if they are readmitted we are dinged. From my understanding from our managers, it doesn't matter the cause of the readmission. So say someone had a MI 3 weeks ago and was admitted, DC'd home and was in a MVC, we will not get paid for the MVC admission. I really hope this is not true, but I haven't researched it on my own yet. I don't see how this is going to work sadly.
I see this as identifying problems with diligent monitoring of patients while still in the hospital. I recall while working on a cardiopulmonary step down back in 2010, a post thoracotomy patient I was assigned to was not out of bed for 2 days post op. He asked for assistance to just move forward in the bed, I move him up in the bed and he went into respiratory distress on me. I had to call an RRT, nebs, CXR the whole 9 yards. This was a horrendously busy and heavy nursing unit, and understaffed to say the least for the acuity of patient population. Had the staffing been adequate with a mix of experience levels- (yes, I was the only crabby mean old bat nurse on the floor) with attention to the nursing practices of the days of old, I don't think this would have happened.
These patients were so sick on this unit, right out of CVICU/CVSICU and only in those 2 units for the absolute bare minimum 1,2 maybe 3 days max, they went to those 2 units fresh from the OR- no PACU. With the amount of nurses staffed- I hated every minute I was at work. It was sheer hell. The nurse patient ratio= 5-6:1!!! all telemonitored, with drips, pump, tubes, chest and vascular dressings, sometimes the internal pacing wires were just capped and surgeons pulled them on the floor, not to mention the army of meds they were on. And we discharged from this floor, ?Amount of time to do discharge teaching??? Discharge what??? Throw the discharge instrutions at them was more like it, because SICU was on the phone for the bed. and the supervisor was in your face to see what the hold up was!!! If the patient had to pee before discharge, give them a urinal and tell them to use it on the way home or cross the old legs in the car Which is another issue this regulation is addressing: there needs to be more staff on the floor so the nurse discharging the patient can do a competent job going over discharge instructions. That nurse is the bridge for that transition, but a CEO wouldn't know that.
I hink this is going to fall on the admistations shoulders. I don't think the staff nurses should be accepting blame for this. There's not much staff nursing can do on the staff level.
These patient satisfation surveys are nice CEO ego building fluff BS. If the nurse smiles and does the ADIET script, and behaves like unskilled the maid service the CEO thinks they are, the patient thinks 'service' in this hotel is wonderful. Then gets home and bang- CHF or sepsis a few days to weeks after discharge. Goes to show just how much the CEO really knows the health care industry. This Medicare reg. is objective data.
I also agree- these sick patient's should always be sent home with a Home Health RN next day follow up visit. How come the hospital CEO didn't come up with that solution.
The fines may be just be going into effect, but this has been coming down the pike for 3 years. Our area hospital system hired nurses called "Nurse Navigators." They coordinate with us (the PCPs), make sure we have all of the pertinent hospital records, and arrange all of the discharge planning, out-patient therapies, pharmacy fills, etc. It's been going well and the local system apparently has data that reassures them they are nowhere near having to worry about owing medicare money on readmits. I know they (the Navigators) make my life a helluva lot easier! Sadly, they only use the Navis, as we call them, for the diagnoses being followed for readmit, and only for the allotted time period. They do good work and help the patients a lot. I believe they told us one has to be a MSN prepared RN with gobs of bedside experience under ones belt to be qualified to be a Navi. I've no idea what they are paid, but they apparently save the system a lot of money. I can't believe this is the only hospital system in the country to have prepared for the changes, lol.
I completely agree with you. I was on the floor before going to the ICU. My background was a renal, pts coded almost daily in HD yet DC planning was trying to get them out...why, because reimbursement was cut and although the pt needed to be in the hospital per insurance there admitting dx was a 2-5 day stay only. A time limit on hospital stays was part of the downfall, now hospitals will be fined for readmission's, how is that going to fund more staff. Sounds like we as nurses will be blamed for more while expecting to do more with/for less.
There are quite a few hospitals in my area that have nurse navigators. and there is a company around me who is contracted by the patient's insurance company as a benefit, to do nurse navigator. The video of this company I watched, the nurse navigator goes with the patient to the doctors visit- the example was a patient who just recieved a diagnosis of breast cancer. The nurse navigator listens to the doctor's opinnion with the patient, discuses/explains the doctors infromation with the patient, taps into the data based back at the office for which ever treatment options the patient would like to pursue but does not make any treatment decisions or recommendations for the patient.
In addition there is also private Nurse navigators, a nurse who opened her own office in my area, who the patient can hire on their own. I have her card and got it theough a freind of my.
I have looked into these positions. I don't read that they all have to have their MSN but I do know the consistent requirements through all areas of employment for the nurse navigator I checked into is "atlleast 10-15 years experience", and I if I recall correctly, it has to be 10-15 years acute care bedside.
If the average fine in $125k over a year, I don't think that will have much impact on staffing. The type of places who are going to be fined will try to do more with what they have and hope for the best, but that fine alone isn't enough to justify adding staff.
The places that have positions such as Nurse Navigators have them because they believe it is the right thing to do and probably believe there is a cost benefit, regardless of the new fines.
kcmylorn
991 Posts
http://www.usatoday.com/story/money/business/2012/09/30/medicare-fines-over-hospitals-readmitted-patients/1603827/
Medicare fines over hospitals' readmitted patientsding...
By RICARDO ALONSO-ZALDIVAR, AP
42 minutes ago
My take on this is: This could have positive implications for nurses in that if alot of these hospitals perform poorly, which I think they will, the hospital may have to look seriously at their staffing levels.
The greatest impact on controlling and reducing these readmissions falls under nursing's control. WE are with these patient's 24/7. We are the doctors's eyes and ears. These eyes and ears can only be in one place at one time. Like mentioned- these patients are complex with multiple co morbidities, this is where these hospitals are going to have to face facts. They can't competely take care of this level of complex patient's on a shoe string anymore. They can either increse and hire more nures or pay the fines to medicare. These hospitals need to have enough nurses staffed to competently monitor a patient's progess and the Licensed nurse is the one responsible for discharge teaching. If the staff levels are to low, which we all know they are, this is where the patient's slip through the cracks and are doomed for readmission.
I don't see this as a bad thing. I think it is finially going to make hosptial adminstration face up and be responsible for the poor decisions they have been making .