SCIENCE

Nursing Homes Are Starting to Supplant Hospitals as Focus of Basic Health Care

Israel Sapoznick, 89, a resident of the Hebrew Home at Riverdale received a blood transfusion as an outpatient so he didn't have to go to a hospital. Byron Smith for The New York Times 
Israel Sapoznick doesn’t do well in hospitals.
At 89, he sees poorly, uses a wheelchair, and suffers from mild to moderate dementia. Even the ambulette ride from the Hebrew Home at Riverdale, where he lives in the memory care unit, can prove stressful.
“It is very scary for an older person to be in a hospital, and it’s hard for the family, too,” said his daughter Sirena Silber, 45, who accompanies her father to medical appointments. “He gets very anxious and unhappy.”
So when Mr. Sapoznick was weakened by anemia in February, it came as a relief to learn that instead of going to an emergency room and waiting to be admitted, he could receive an outpatient blood transfusion at nearby Montefiore Medical Center. Transfusions used to involve several days in a hospital, but Mr. Sapoznick returned to his nursing home after a few hours.
He received intravenous fluids for two days that month, too, after a period during which he wasn’t eating and drinking much. IV therapy also used to require a hospital stay. Like a growing number of facilities, however, the Hebrew Home provides IVs for antibiotics, diuretics and other drugs, or for hydration. Mr. Sapoznick didn’t need to leave his room.
Hospitalization for these kinds of treatments “should be a thing of the past, but it’s not,” said Dr. Zachary Palace, a geriatrician and medical director of the Hebrew Home, in the Bronx.
The notion that a hospital remains the safest place for old patients dies hard. Many families still believe their aging relatives belong in a hospital when they’re ailing. But 20-plus years of research have documented the risks of hospitalization for older adults, particularly those frail or ill enough to need nursing home care.
In hospitals, old people fall. They contract stubborn infections. They can develop delirium from unfamiliar surroundings and drugs, and bed sores and loss of conditioning from inactivity. They lose functional abilities, including cognitive skills, that they may never regain, especially if they’re already sliding into dementia.
Certain procedures and treatments require hospital admission, of course. But “the push is to reduce unnecessary hospitalization for things that can be handled in skilled nursing facilities,” said David Siskind, the medical director at the Gurwin Jewish Nursing and Rehabilitation Center in Commack, N.Y.
Gurwin provides IVs and dialysis on site, and outpatient transfusions at a nearby hospital. A medical practice comes to the home to insert catheters called PICC lines for long-term intravenous medication.
Changing Medicare and Medicaid policies and incentives, and new HMO-like accountable care organizations, are encouraging these practices. But there would be greater optimism if nursing homes were adopting them faster.
“It’s a slowly growing number, not a tidal wave,” said Dr. Leonard Gelman, the immediate past president of AMDA — The Society for Post-Acute and Long-Term Care Medicine, which represents doctors, nurse practitioners and physician assistants working in nursing homes. “There’s a mismatch between facilities’ capabilities and what they want to do.”
A major obstacle to offering more procedures is a fact that often shocks families: Many of the nation’s 16,000 or so Medicare-certified nursing homes don’t employ round-the-clock registered nurses. Federal regulations require them only eight hours a day. Five states — Rhode Island, Connecticut, Hawaii, Maryland and Tennessee — mandate 24/7 nursing coverage; in several other states, staffing requirements are tied to facility size.
Starting an IV — probably the most common procedure that nursing homes could reclaim from hospitals — without a registered nurse always on duty can be problematic.
“If the nurses start it in the afternoon and there’s a problem at 3 a.m., what do you do?” Dr. Gelman asked. The Saratoga Center for Rehab and Skilled Nursing Care in Ballston Spa, N.Y., where he practices, does employ round-the-clock R.N.s. In facilities that don’t, an IV problem would probably land patients in a hospital anyway.
Medicare reimbursement policies also give nursing homes incentives to transfer patients to hospitals. The homes receive fixed daily amounts to care for residents, and those rates don’t rise if someone needs, say, expensive IV antibiotics.
“Facilities don’t want these high-cost patients in their buildings,” Dr. Gelman said. “Once they send a patient out, even the ambulance is paid for by someone else.”
Gurwin, with 460 beds, and the Hebrew Home, with 855, are so much larger than typical nursing facilities, which average 100 beds, that they can afford more innovative approaches. They’re also nonprofit organizations with substantial philanthropic support. Being in or near a major city also makes staffing and arrangements with outpatient facilities simpler than it is in rural areas.
But their efforts demonstrate what’s possible and why more at-home treatment for residents makes sense. At the Hebrew Home, Dr. Palace said, residents needing transfusions previously spent three to four days in the hospital, while specialists conducted the usual series of tests that nobody had requested.
“People never came back healthier than when they left us,” he said.
Digging through data compiled by the federal Agency for Healthcare Research and Quality, Dr. Palace recently found that Medicare patients spent an average of 5.3 days in a hospital for blood transfusions in 2012. The mean cost: $10,339.
Outpatient transfusions at Montefiore, by contrast, cost Hebrew Home residents $350 for the same-day procedure and $217 for a unit of blood, and transportation.
In 2006, Dr. Palace said, the home sent about 70 residents to hospitals each month, for all sorts of reasons. By last year, that number had dropped to 30 to 35. “We cut our hospitalization rate in half, and in large part it’s due to these programs,” he said of the effort to perform more routine procedures at the facility.
Savings like that will interest federal agencies seeking to control health care costs, but older adults also benefit. Families often regard the hospital as a protective haven, a place where lives are saved — not where infections develop or muscles atrophy. “We have to educate people,” Dr. Siskind said.
He now frequently tells families, “It’s better for your 85-year-old mother to stay here, where she knows us and we know her.”