Dr. Joseph Ouslander
Dr. Joseph Ouslander

Once again, Dr. Joe Ouslander points the way to a greater understanding of the complexity of hospital readmissions from Long-Term Care settings.  Because Long Term Care (LTC) comprises a distinct set of services, settings, interdisciplinary team members, and trade-off’s between benefits and burdens of a given decision to hospitalize, the measures currently used for hospital readmission payments or penalties fall short.  Ouslander and Maslow summarize their exhaustive look into the design, validity, and evidence base for various measures of potentially preventable hospitalizations that have been considered since the 1990’s.  (The exhaustive search is on line in a Long-Term Care Quality Alliance white paper.One surprising finding was how rarely the literature on potentially preventable hospitalizations reviewed or even mentioned the Emergency Department.  Nearly half of all hospitalizations begin in the Emergency Department (ED), and 60% of all nursing home residents will visit the ED every year.  The role of ED staff and physicians, their perceptions of available resources among LTC providers, and the set of tools they have on site to care for complex geriatric patients with multiple co-morbid conditions; all of these can impact the decision to admit a frail patient from LTC settings.

The authors are correct when they say that the use of rehospitalization metrics will only increase.  In the community, nursing homes are already seeing an effort by Accountable Care Organizations (ACO) and hospital systems to stratify, or ‘prune’ their network of LTC providers.  Central to that effort is a comparison of rehospitalization rates, albeit unadjusted and often unlinked from transitional care processes that are known to influence the outcomes of hospital transfers to LTC.  Reports like this one highlight the limitations of that approach, and the need for further research into the factors that influence readmissions, both in and out of the hospital itself.