Nursing facilities – A medical crisis requiring a prescription

David Chess, MD

Nursing facilities have evolved from nursing homes to medical facilities over the past 20 years.

Patients are sicker, older, have more medical comorbidities and are more fragile. They need more help with activities associated with daily living and have much higher rates of cognitive impairment. People over the age of 85 are the fastest growing demographic group, and the elderly segment of the US population is expected to double in 2030 compared to 2010.

Even with a shift to providing higher-intensity care in people’s homes, the demand for care at the nursing facility level is expected to double. Meanwhile, there are significant workforce challenges that prevent nursing home patients from getting the medical care they need. Fortunately, telehealth can help fill these gaps.

Seema Verma

The availability of clinicians has always been a challenge. The medical community too often shuns nursing facilities, with less than 1% of medical school graduates choosing to work in geriatrics. The total number of board-certified geriatricians in the United States has fallen from over 10,000 in 2000 to less than 8,200 today. By 2030, we should have fewer than 7,300 geriatricians nationwide. Approximately 50% of spaces in geriatrics training programs go unfilled each year.

Among the many challenges these staffing shortages cause is that they prevent facilities from accepting new patients because they don’t have the staff. This, in turn, clogs up hospitals as they have no place to offload patients, prolonging hospital stays and increasing costs.

Too often, state and federal investigators evaluating nursing care facilities focus on outdated regulations regarding site visit requirements rather than other attributes that better define quality care, such as comprehensive ratings with plans. usable care or timely care on admission or readmission. Current federal requirements introduced in 1991 require patients to be seen onsite by a physician within one month of admission and monthly for an additional two months, after which the patient must be seen at least every two months.

A disproportionate number of hospitalizations occur within 10 days of admission to a nursing facility, and more than 10% of patients admitted to a nursing facility never see their doctor. For patients not seen, the risk of hospitalization is double that of patients who have been seen. In addition, nearly 40% of hospital admissions are preventable. These potentially preventable hospitalizations cost Medicare roughly more than $1 billion a year, not to mention the personal toll of a fragile population and their loved ones.

Current regulations, although well-intentioned, do not take into account new technological advances via telehealth, nor respond to the clinical needs of patients. Simultaneously, they create an administrative and operational burden for the many underfunded and underfunded institutions, which often cannot be met. Further, regulation does not reflect the reality of our growing gap in the clinician workforce.

The standard of care should be for one-time and face-to-face (virtual or on-site) visits. People should be seen and clinically assessed within 72 hours of admission and immediately if there is a change in condition, not just once a month unless they are hospitalized. Today, when a patient has a change in condition, the clinician is called and orders are given to treat or send the patient to hospital.

Telemedicine can help solve this problem.

Telemedicine – defined as two-way video, a digital stethoscope allowing the clinician to listen to the patient’s heart and lungs, an otoscope and a wound care camera – can provide on-demand care and reduce hospitalizations. Telemedicine equipment is inexpensive to implement and almost universally available, with high-speed Internet access even in most rural areas. In a 2018 study, an after-hours telemedicine program at a facility with 365 patients averted 91 hospital admissions over the one-year study period, with a net saving planned for Medicare of more than $1.3 million.

Allowing telemedicine visits within the regulatory framework and updating clinical requirements to be in line with science regarding rehospitalization would enable on-time care, high patient satisfaction, reduced hospitalizations and lower burdens administrative burden for our already overburdened nursing facilities.

We need to modernize federal regulations to allow both urgent and follow-up visits to be provided via telemedicine. Creating an improved standard such that all people must be seen within the first week of admission and allowing telemedicine visits to meet the monthly visit requirement would go a long way to closing the clinical care gap.

We call on Medicare to update its regulations if we are serious about improving care for America’s most vulnerable population – our seniors.

David Chess, MD, is Chief Health and Policy Officer, Chairman of the Board and Founder of Tapestry Health.

Seema Verma is the former administrator of the Centers for Medicare & Medicaid Services.

The opinions expressed in McKnight Long Term Care News guest submissions are those of the author and not necessarily those of McKnight Long Term Care News or its editors.


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