Keeping people out of the hospital whenever possible is a big focus for health care these days, and it's only going to get bigger. A new report and an emerging type of physician are focused on exactly that goal, particularly for older Americans.


Hot on the heels of CMS' launch of its value-based purchasing program, the Medicare Payment Advisory Commission released a report last week asserting that 59 percent of emergency department visits and 25 percent of hospital admissions could be avoided for seniors if they received better care at home or in an outpatient setting.

Upper respiratory infections accounted for most of the preventable ED visits by the Medicare recipients studied. Heart failure was the most frequent cause of preventable hospital admissions. As reported by Phil Galewitz in Friday's Kaiser Health News blog, patients could avoid some ED visits "by having health conditions treated by family doctors or urgent care centers or by making sure to take all their medicine." And the number of hospital admissions could be reduced "if conditions such as asthma, diabetes or heart failure were better monitored by patients and their doctors."

How exactly to accomplish those things is an open question, especially with the critical shortage of primary care physicians. Some policymakers are pushing to broaden the scope of practice for nurse practitioners and physician assistants. Technologies to allow clinicians to continuously monitor patients in their homes or in remote locations and to remind them to take their meds are evolving rapidly, though they can be expensive to purchase and maintain. Most significantly, hospitals in some communities are convening physicians, post-acute providers and public health agencies to build tighter relationships and to safely share patient information and to generally improve the local care continuum.

Another strategy for keeping older patients out of the hospital may be gaining traction in nursing homes. SNF-ists, sometimes called SNF-ologists, are physicians who practice full time in skilled nursing facilities. The SNF-ist usually works with patients who have multiple comorbidities and who are at high risk of readmission. Patients discharged to a nursing home are able to see a SNF-ist more quickly and more frequently than they could see their primary care physician.

A report last week from Curaspan Health Group estimated that there are only a couple of thousand of these nursing home specialists now practicing, but that the benefits are clear: preventable hospitalizations are more expensive than treating a nursing home patient on site; transfers to the hospital and back to the nursing home expose patients to infections, confusion and agitation; there is a risk that records will not follow the patient from one care setting to another; and, of course, a SNF-ist would be available quickly when a patient's condition shows signs of deteriorating.

The Curaspan report also points out the obstacles to the SNF-ist model: nursing homes need to make a significant upfront investment to pay them competitive salaries, and payers may balk "if they believe the scheme is increasing nursing home patients' claims for physician services."

As we've noted frequently in this space, America's aging population is growing fast and the pressure on our health care system will increase accordingly. Finding new and better — and less costly — ways of delivering care is a national priority.