Nursing Home Tackles Readmissions with In-house Primary Care

September/October 2013

Nursing Home Tackles Readmissions with In-house Primary Care


Across the country, healthcare providers are grappling with high rates of readmissions to hospitals within 30 days after discharge. Readmission to the hospital is stressful for patients and their families; costly; and, many times, avoidable.

In southern Oregon, Pinnacle Healthcare, Inc., has implemented a system of in-house primary care at three of its nursing homes that has greatly reduced readmission rates. For the nursing homes, the services allow them to better coordinate care and address many issues without having to transfer a resident to the hospital. For residents and their families, the new system gives them something impossible to put a price on: peace of mind.

Bringing Communities Together to Address a Shared Challenge
Pinnacle’s investment in primary care was inspired through its involvement in a regional network convened by Acumentra Health to support evidence-based approaches for reducing readmissions across healthcare settings at the community level. Stakeholders in every state are engaged in similar efforts through Medicare’s national Quality Improvement Organization program. (In JAMA, Brock et al. [2013] describe results from a QIO-led pilot program completed in 2010.) As Oregon’s QIO, Acumentra Health brought together healthcare leaders in four regions, identified through claims data indicating a potential for improvement. In southern Oregon, the regional community encompasses three small cities and comprises four hospitals, nine nursing homes, several assisted living and residential care providers, two hospices, seven home health agencies, mental health services, and other stakeholders.

At the Southern Oregon Community’s kickoff meeting in spring 2012, Acumentra Health shared Medicare claims data that made participants aware of their readmission rates and helped them begin to examine the causes. The detailed reports showed where discharged patients went after leaving the hospital and which settings in the community were readmitting more patients than others. Providers also received data specific to their facilities. The rates came as a surprise to some, including Pinnacle.
Upon learning that Medicare fee-for-service claims data showed the 30-day all cause readmission rates for its facilities running between 16% and 20%, Pinnacle managers and facility administrators decided to push up the timeline for a new strategy they planned to implement in the fall—the use of in-house primary care services to provide ongoing care, with a key goal of keeping residents out of the hospital when possible.

“The data opened our eyes to the extent of the issue,” says Jason Fiske, administrator at Pinnacle’s largest southern Oregon facility, Highland House Nursing and Rehabilitation Center. “We believed strongly that a primary care service could make a difference in our facilities.”

The Doctor Is Always “In” at Highland House
Having primary care on staff is “cutting edge” among Oregon nursing facilities. Highland House, Pinnacle’s 174-bed facility in Grants Pass, Oregon, had been run like many other traditional nursing homes. The medical director maintained a private practice in addition to coordinating care for residents at Highland House. More than 20 area doctors also provided care for residents, often interacting with nurses and staff by phone, fax, and mail. This traditional system of multiple doctors communicating with staff and caregivers complicated the coordination of care.

Circumstances changed dramatically when Pinnacle engaged a full-time medical director and hired two nurse practitioners. Among them, they provide in-person coverage four days a week at each nursing home; the three professionals rotate on-call duty. The medical staff works with the resident, family, or community primary care physician to encourage transfer of primary care responsibility to the nursing home staff.  This status empowers them to do more than just monitor for emergencies—they can intervene to deliver care if a resident’s condition changes.

Christina Ford, MD, is the medical director for Highland House and for Pinnacle’s two other southern Oregon facilities. Her presence on site, as well as her ability to stay in frequent communication with the nurse practitioners and staff, has resulted in dramatic improvements, not only in the number of readmissions but also in the quality of care provided to the residents.

“This is totally different from trying to run an office practice and doing nursing home care on the side. Essentially, this is our office practice,” says Dr. Ford. “We’re here a lot, and we try to maintain a presence as well as consistency in how we deal with ongoing patient issues. We can circumvent problems early before they get to be huge problems that require hospitalization.”

In addition to staying current with residents’ conditions and care, Dr. Ford helps smooth the transition of new residents moving from the hospital to the nursing home. “I look at medication lists for everyone who is admitted that day so that I can make sure there are no inaccuracies or conflicting medications. Doing the medication reconciliation on the day the patient arrives prevents problems down the line.”

Dr. Ford, who was previously a hospital physician herself, also makes a point of personally checking in with the hospitalist who had been in charge of a new resident’s care. “If the nurses have questions when the patient comes to the nursing home, they can page me and I can usually clear up the question based on the information I was given by the discharging doctor at the hospital.”

Efficient communications flow is a key element to reducing hospital readmissions at Highland House. “For nursing and therapy services to receive answers regarding residents’ medical issues in less than 24 hours is a definite benefit of in-house care,” says Bonita Acosta, NP, one of Pinnacle’s nurse practitioners. She adds that the frequent interaction among the nursing staff, the nurse practitioners, and the medical director has helped the nursing staff do their jobs better. “It empowers them to start making better clinical assessments and ask more pertinent questions.”

Mr. Owens’s Story
Billy Owens is typical of fragile nursing home residents with complex medical histories who—under a traditional model of nursing home care—are frequently readmitted to the hospital. Mr. Owens is a retired military veteran who served in Vietnam. During his adult life, he’s dealt with diabetes, prostate cancer, the loss of a foot, heart failure, and cardiomyopathy.

“I used to see him frequently when I worked in the hospital,” says Dr. Ford. “Every month or six weeks he’d be admitted, usually for congestive heart failure exacerbation. Now, I know his history. If a nurse at Highland House calls and says, ‘Billy is really short of breath today,’ I can ask whether he’s getting his Lasix, has he missed any medications, what his weight is doing, are his legs swollen, how much salt he’s had. Because I know his history, I can stay on top of his problems before they become huge problems that require hospitalization.”

Wilgard Owens, Mr. Owens’s wife of 57 years, says she wouldn’t be able to care for her husband at home and used to worry about the time it would take for an ambulance to reach their home in rural Josephine County. “He’s very sick, but I know he’s being looked after. If there’s an emergency, there’s help available. They stay on top of things and coordinate his care at Highland with VA services. This gives me great peace of mind.”

Good for the Resident, Good for the Company
The implementation of in-house primary care at Highland House is working. The average 30-day all-cause readmission rate for the first quarter of 2012 was 23% (Medicare fee-for-service claims data). Since primary care services began, the average readmission rate has dropped to 14%, a 34% improvement in the rates. This rate is dramatically lower than similar rates for skilled nursing facilities in the community (20%), for Oregon facilities (22%), and for facilities nationally (24%) for the second and third quarters of 2012.

Pinnacle made a strategic business decision when it implemented in-house primary care. So far, the approach is paying for itself, since the facilities can bill Medicare Part B for providing primary care services. Tracking and analyzing their own clinical and readmissions data using an in-house information system helps them to demonstrate the value of these services.

In addition, Highland House has implemented INTERACT II, a nursing home-oriented strategy for reducing readmissions that incorporates structured communication and protocols for handling specific clinical situations. Highland House schedules RNs instead of LPNs on their skilled care units so the nurses can perform resident status assessments. Nursing staff are also learning directly from the medical staff through in-service training on topics related to post-hospital care, such as use of total parenteral nutrition, IVs, and vacuum-assisted closure devices for wounds.

Pinnacle’s leadership is proud of the results. “In addition to reduced readmissions, we have seen improvement in our care delivery and survey compliance,” says Steve Wallace, NHA, senior vice president of operations. “We intend to spread this model throughout our facilities.”

Dr. Ford sees great potential in the in-house primary care model and salutes the financial commitment shown by Pinnacle to make it happen at its facilities. “It’s a really worthwhile way of operating. We’re never going to get the recidivism rate down to zero, but being aware of what’s going on, keeping in touch with the patient, and keeping in touch with the nurses helps quite a bit.”

Jennifer Wright, quality improvement specialist for Acumentra Health’s nursing home and readmissions initiatives, is a licensed nursing home administrator with more than 10 years of experience in the long-term care industry, including continuing care retirement communities and not-for-profit and for-profit skilled nursing facilities. She is a Certified Professional in Healthcare Quality. She holds a bachelor of science degree in healthcare administration with a gerontology certificate from Oregon State University. Wright may be contacted at

This material was prepared by Acumentra Health, Oregon’s Medicare Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

Brock, J. et al. (2013). Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries. JAMA, 309, 381–391. Available at
Interventions to Reduce Acute Care Transfers (INTERACT) tools are available online at Accessed 5/27/13.