Read­mis­sion re­la­tion­ship

But costs put damper on rais­ing RN staffing lev­els

Modern Healthcare - - Cover Story - Mau­reen McKinney

New re­search high­light­ing the re­la­tion­ship be­tween reg­is­tered­nurse staffing lev­els and hos­pi­tal read­mis­sion rates is draw­ing praise from pro­fes­sional as­so­ci­a­tions and ex­perts.

But even as hos­pi­tals rec­og­nize the im­pact nurses have on pa­tients’ post-dis­charge uti­liza­tion, pay­ment bar­ri­ers of­ten keep them from beef­ing up staffing lev­els.

“We’re in an era of cost con­tain­ment, so there is a de­sire to staff as tightly as pos­si­ble,” said Mar­i­anne Weiss, as­so­ciate pro­fes­sor of nurs­ing at Mar­quette Univer­sity, Mil­wau­kee, and lead au­thor of the study. “In­creas­ing nurse staffing lev­els can have a pos­i­tive im­pact on costs down the road, but that fi­nan­cial in­cen­tive goes to the payer. As health re­form goes for­ward, we want to see if we can put that money in the right place.”

For the study, which ap­peared in the jour­nal Health Ser­vices Re­search, Weiss and her col­leagues used elec­tronic med­i­cal­record data, billing data and ques­tion­naires from nearly 1,900 pa­tients treated at four hos­pi­tals dur­ing the first seven months of 2008. They an­a­lyzed how nurse staffing lev­els af­fected dis­charge readi­ness, post­dis­charge emer­gency vis­its and pre­ventable hos­pi­tal read­mis­sions.

“We looked at dis­charge teach­ing be­cause it af­fects how ready pa­tients are to go home, and that, of course, af­fects read­mis­sions,” Weiss added.

Dis­charge teach­ing en­com­passes ev­ery­thing nurses do to pre­pare pa­tients and their fam­i­lies to man­age their care, in­clud­ing ed­u­cat­ing pa­tients about disease red flags, med­i­ca­tion ad­her­ence and physi­cian fol­lowup. And when nurses are pressed for time, that dis­charge teach­ing of­ten gets short­changed, the re­searchers said.

Specif­i­cally, they found that while higher non-overtime RN staffing lev­els low­ered the odds of read­mis­sions, higher overtime staffing lev­els in­creased the like­li­hood that pa­tients would visit the emer­gency depart­ment soon af­ter dis­charge.

“We’re pleased to see an­other unit-level study like this one,” said Katie Brewer, se­nior pol­icy an­a­lyst for the Amer­i­can Nurses As­so­ci­a­tion. “While we have ro­bust data on the im­pact of staffing on pa­tient care on the fa­cil­ity level, unit-level re­search makes a stronger case.”

Brewer agreed that most hos­pi­tals view staffing as some­thing that goes in the cost col­umn on their bal­ance sheets. The chal­lenge, she says, is to make the busi­ness case that ap­pro­pri­ate lev­els of nurse staffing can im­prove pa­tient care and pre­vent later costs.

“Staffing can be a value-added as­pect, es­pe­cially as we move into an era of val­ue­based pur­chas­ing and ac­count­able care or­ga­ni­za­tions and we get paid for bet­ter out­comes,” Brewer said. Ac­cord­ing to Dr. Karen Joynt, a fel­low in car­di­ol­ogy at 773-bed Brigham and Women’s Hos­pi­tal, Bos­ton, and a fel­low in health pol­icy at the Har­vard School of Pub­lic Health, read­mis­sion rates are af­fected by many fac­tors, mak­ing it dif­fi­cult to draw con­clu­sions about cause and ef­fect. Hos­pi­tals that have low nurse staffing lev­els are likely to be fi­nan­cially strained and could be re­source-poor in other ar­eas as well, she said.

Joynt co-authored a re­cent study in the jour­nal Cir­cu­la­tion: Car­dio­vas­cu­lar Qual­ity and Out­comes about hos­pi­tal read­mis­sion rates for heart fail­ure, which found that pa­tients dis­charged from hos­pi­tals with low lev­els of nurse staffing had higher read­mis­sion rates than hos­pi­tals with higher staffing lev­els.

While Joynt agreed that dis­charge teach­ing im­proves pa­tients’ readi­ness, she also ar­gued that poli­cies that fo­cus on re­duc­ing read­mis­sions—par­tic­u­larly those poli­cies that in­clude penal­ties— could tar­get cash-strapped hos­pi­tals that serve vul­ner­a­ble pop­u­la­tions.

“It’s im­por­tant go­ing for­ward to re­ally be mind­ful of how these poli­cies might im­pact a num­ber of dif­fer­ent health dis­par­i­ties,” Joynt said.

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