Florida's hospitals are tackling one of the most vexing and costly problems in health care — the revolving door between hospitals and nursing homes.
For example, St. Anthony's Hospital in St. Petersburg recently realized that some heart failure patients were returning not because of cardiac problems, but for infections. Now it's working with a local nursing home to catch the warning signs of infection early, avoiding an emergency return to the hospital.
Such steps make good sense for patients' physical and emotional wellbeing. Yet hospitals and nursing homes traditionally have had little financial incentive to team up because of how government health care programs reimburse providers.
That's about to change, with new government penalties aimed at reducing hospital readmissions among the estimated one in four seniors discharged to nursing homes who end up back in the hospital within a month.
These return trips cost the nation more than $4 billion a year, experts say, leaving many patients in worse condition. Not all returns can be avoided, but as many as half could be prevented.
"We can improve care and reduce (complications of hospitalization) and reduce unnecessary expenditures all at the same time," said Dr. Joseph G. Ouslander, senior associate dean for geriatrics at Florida Atlantic University's medical school and the author of a recent article about the problem in the New England Journal of Medicine.
"The trouble with frail elderly people in nursing homes is that when they go into the hospital, they often get worse," he added.
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For the past three years, the Florida Hospital Association has been tackling readmissions with the help of new technology that tracks patients returning to hospitals within 15 days.
As a result, Florida hospitals logged an 11 percent drop since 2008 in readmissions for five common conditions, the association says — heart attack, heart failure, coronary bypass surgery, hip replacement and pneumonia. But the association still is concerned about high numbers for patients discharged to nursing facilities.
"We realized that the handoff from the hospital to the nursing home was a point of vulnerability where things could potentially fall through the cracks," said Denise Remus, a nurse and chief quality officer for BayCare Health System, which includes St. Anthony's.
As the length of hospital stays has decreased in recent years, she noted, patients are being released to nursing homes earlier than in the past. Some still need breathing equipment, intravenous feeding and other technologies.
The Florida Hospital's Orlando-based system has been studying the Medicare patients it sends to nursing homes. It learned that readmissions vary hugely, from the single digits to more than 80 percent.
And at one nursing home, it found that more than half of the heart failure patients weren't even seen by a doctor before getting readmitted to the hospital.
"The perception is that there's a lot more oversight than what you see in actuality," said Dr. Ross Edmundson, an executive at the central Florida hospital system.
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Last year, St. Anthony's Hospital began to work with Pinellas Point Nursing and Rehabilitation to reduce readmissions for heart failure patients and saw that many were returning with sepsis, a dangerous infection that can develop at any point in treatment, but can take time to become apparent.
So the nursing home started screening for patients considered at risk, running lab tests and watching for early warning signs like fever and confusion.
Within six months, it had eliminated sepsis as a reason for readmission to St. Anthony's, said Deborah Eady, director of nursing at the facility. Readmissions still happen; one patient, for example, was terminally ill. Another had ongoing heart problems. But the partnership was eye-opening.
Hospitals "are only going to treat what they actually observe," Eady said. "When (patients) leave the hospital, that's when we have to deal with the rest."
But hospitals get paid for the patients they admit, not for those that stay away. And nursing homes don't benefit financially from staffing up to prevent repeat hospitalizations.
"It's sort of like the right hand doesn't know what the left hand was doing, or doesn't care," said Vincent Mor, a professor of public health at Brown University who has studied the issue.
But in about a year, hospitals with high readmission rates stand to lose a small portion of Medicare revenue.
This month, several hospitals and nursing homes in Tampa Bay are testing out a new tool — a discharge form that seeks to put everybody on the same page.
It features check boxes for nurses and doctors, reducing the potential for errors from illegible handwriting. There's also a diagram of the patient's body, so hospitals can identify potential skin sores to watch for infection.
"Hospitals, traditionally, we've been focused on hospitals," said Remus, the BayCare quality officer. "We have to look at our whole system of care."
Times researcher Shirl Kennedy contributed. Letitia Stein can be reached at firstname.lastname@example.org.