Nursing homes seen deficient on basic care

Tens of thousands of nursing home residents must be sent to the hospital each year because of a breakdown in basic medical care at the facilities, specialists say, a scenario that exposes frail elderly people to unnecessary trauma and illness.

More than one-third of all hospitalizations of nursing home residents could be prevented if nursing staff recognized symptoms of increasing illness sooner and doctors were more readily available at the nursing homes, a new national study said.

``Things get overlooked until a hospitalization is unavoidable," said Mary E. McKenna, the state's chief consumer advocate for nursing home residents. ``The quality of primary care . . . has not been up to what people expect."

Now, there is a growing movement in Massachusetts and elsewhere to strengthen medical care at nursing homes and cut unnecessary hospitalizations.

A New Bedford nursing home began using telemedicine a month ago to give patients immediate access to doctors evenings and weekends. HealthBridge Management, which owns the nursing home, plans to expand the videophone doctor visits to many of its 14 other Massachusetts nursing homes over the next year. Already, the program has averted at least six trips to the emergency room.

More nursing homes are hiring nurse practitioners, some on call 24 hours a day, to provide intensive, hands-on primary care. Many of the nurse practitioners work with Evercare, a for-profit Medicare HMO that serves 6,300 nursing home residents in Massachusetts and tens of thousands more nationwide. A national study of Evercare's impact on nearly 2,000 patients over two years found a 65 percent reduction in preventable hospitalizations. Evercare also pays doctors more than the typical rate, and its physicians see patients more often than average.

The state is targeting four conditions that frequently result in avoidable hospitalizations -- dehydration, urinary tract infections, chronic pulmonary disease, and congestive heart failure. At workshops cosponsored by the state trade group for nursing facilities, nurses and aides are taught to identify subtle changes in patients' health that may signal a developing problem and to intervene quickly and effectively.

In Canada, researchers recently found another approach that works: clear and simple treatment instructions. By providing standardized care for pneumonia -- including antibiotics, intravenous fluids, and increased monitoring by nurses -- they reduced hospitalization s by more than 50 percent, according to a study published last month in the Journal of the American Medical Association.

Bruce Cartwright saw first hand how repeated, unnecessary trips to the hospital wore down his 92-year-old mother. Dorothy Cartwright was getting treatment for a broken hip at a nursing home when she started to feel weak and her blood pressure dropped. No doctor was available, and Cartwright said the nursing staff ignored his suggestion that she was experiencing a recurrence of a long standing condition in which her blood pressure fluctuated dramatically as she moved.

``Right away, they sent her off to the emergency room," said Cartwright, of Dartmouth. ``She sat around for five or six hours, getting really frustrated and angry. They did all kinds of tests and realized there was nothing wrong. . . . So, they sent her back to the nursing home."

Within weeks, she was rushed to the hospital twice more and admitted for a few days, only to be diagnosed with the same blood pressure fluctuations. During a later hospitalization for pneumonia, she caught two other infections that caused high fever and vomiting, he said.

``The hospital and emergency room should be a place for emergencies ," Cartwright said. ``If you don't have to leave the nursing home, you're so much better off."

Moving nursing home residents to hospitals can be very disruptive and disorienting, particularly for patients with dementia. And hospitalizing frail, elderly patients often results in unintended problems, such as bedsores, infections, and decline because of immobilization.

The impact of preventable hospitalizations was highlighted in a study funded by the National Institute of Aging. The study was presented in May at the national meeting of the American Geriatrics Society.

Orna Intrator, a research associate professor at Brown University, used Medicare records to conclude that over a five-month period, 37 percent of the hospitalizations of long-term residents at urban nursing homes nationwide were potentially avoidable. In Massachusetts it was 36 percent. If this pattern holds true for all nursing home residents, the hospitalization of 165,000 residents could have been prevented.

Federal rules require that doctors oversee each nursing home patient's care, but mandate little face time. A doctor must see a resident once every 30 days for the first three months and then once every 60 days. After the first month, a nurse practitioner's visit can be substituted for every other doctor's visit. When a patient's condition changes, the nursing home is required to contact the patient's physician, but that doctor does not have to visit.

Some nursing home patients are treated by their primary care doctors, but most are cared for by a physician affiliated with the nursing home -- and these doctors are seldom available.

A 1997 national survey indicated that doctors who practice in nursing homes spend on average less than two hours per week there, since the nursing home is usually the third priority, after office visits and hospital rounds. Some doctors blame infrequent visits on low reimbursement from insurers; others cite excessive regulations and paperwork.

Nurses say they are frustrated by their inability to get doctors to immediately respond to calls about the patients.

``Except in an emergency, rarely would you get a call back the same day," said Elaine Tetreault, director of nursing at New Bedford Health Care Center nursing home. ``If you're dealing with a covering physician, they're not familiar with the resident, many aren't even familiar with the nursing home industry. So 90 percent of the time, they tell you to send the patient to the ER."

Doctors also are more likely to send a nursing home resident to the hospital if the family insists or if the doctor fears being sued for malpractice, according to a US government report last fall.

Studies suggest that nursing homes with more quality staff have lower rates of hospitalization. Others support the use of telemedicine .

At New Bedford Health Care Center, telemedicine coverage offered by a group of emergency department doctors is providing immediate consultations with patients and decisions on treatment, Tetreault said.

A physician from PhoneDOCTORx, the company created by doctors at St. Luke's Hospital, monitors the two-way videophone connection most evenings and day hours on the weekends. Because the nursing home was struggling to find doctors to visit during the day, PhoneDOCTORx provides a nurse practitioner who works at the nursing home daily and a physician who sees each patient in the rehabilitation wing once a week.

On June 16, PhoneDOCTORx helped 85-year-old Margaret Rimmer avoid a trip to the emergency room after her arm began to swell. A nurse called PhoneDOCTORx and wheeled the video console to Rimmer's bedside. ``I had to hold my arm up to show him," she said of the phone doctor. ``He can see you, and he's talking with you. This is just wonderful."

Joe DeMedeiros said the videophone connection at New Bedford helped ease his father's last hours. Jose DeMedeiros was dying of cancer and HIV, his son said, and on Father's Day, they were agonizing about whether his father should get another blood transfusion. The DeMedeiroses used the videophone to meet with a doctor ``face-to-face" for a conversation. Joe DeMedeiros said it was ``just like him coming to visit personally."

The doctor said he could send an ambulance immediately, but that the transfusion would add just days to his father's life. Father and son decided against the trip to the hospital.

Said Joe DeMedeiros, ``This way he could go in peace."

Alice Dembner can be reached at dembner@globe.com.