Better care for older patients

August 1st, 2017

Three nontraditional initiatives to improve care for elderly patients at JPS Health Network were selected from more than 7,000 submissions for peer-reviewed presentation at the 21st World Congress of the International Association of Gerontology and Geriatrics.

Stephanie Spohr, Reena Matthews, Yvonne Hardin and Lesca Hadley at the 21st World Congress of the International Association of Gerontology and Geriatrics

Stephanie Spohr, Reena Matthews, Yvonne Hardin and Lesca Hadley at the 21st World Congress of the International Association of Gerontology and Geriatrics

The three projects are focused on what happens to patients after they leave the hospital — a departure from tradition, which says the hospital’s job is done once a patient is discharged. The federal Medicare program is encouraging the shift, giving hospitals financial incentive to prevent patients from bouncing back. Medicare penalizes hospitals with high 30-day readmission rates.

Some elderly patients leave the hospital for a long-term care facility. JPS teamed up with seven long-term care facilities to see if care coordination could help patients do better, reducing the odds of readmission. Caregivers in those facilities undergo training and work with JPS team members to ensure patient needs are met post-discharge.

In the project’s first 15 months, the hospital’s long-term care partners prevented approximately 210 hospital readmissions. With the average cost of such readmissions being $9,387, the project produced potential savings of about $2 million.

“Improved partnership between hospitals and long-term care providers allows for standardized communication and information sharing,” reported Stephanie Spohr, PhD, data extractor for Geriatrics and lead author on all three abstracts presented at the 21st World Congress in San Francisco July 23-27.

JPS Geriatrics also shared results of a similar initiative involving skilled nursing facilities, which produced a 4.1 percent decrease in hospital readmissions.

The third project involves home visits for patients with mobility issues, who tend to over-use the emergency room and inpatient hospitalization because they cannot keep primary care office visits.

For patients enrolled in the home visit program, Spohr took a three-month before-and-after look at home visits and found a 38 percent reduction in emergency room visits and a 58 percent reduction in inpatient admissions.

“Receiving primary care visits in the home demonstrates an effective way to prevent both Emergency Department and inpatient visits, thereby avoiding unnecessary hospital utilization, improving patient outcomes and reducing healthcare costs,” Spohr reported.

Spohr attended the World Congress with Nurse Practitioner Yvonne Hardin and Drs. Lesca Hadley and Reena Matthews. Their collaborators include Surendra Mandapati, Jorge Sanchez, Monique Barber and Geneva Mugi, RN.


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