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The race to reduce hospital readmissions

February 6, 2013
by Julie Thompson
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LTC providers share effective strategies
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A long-term care community in Orangeburg, S.C., was getting a dress rehearsal for future industry changes when it stepped up in 2005 to help an 80-year-old man continue living alone in his home after multiple heart procedures.

The Oaks—a non-profit Methodist community nestled within one of Orangeburg’s wooded areas—decided to create an option for the gentleman, who had been told by medical professionals that it would be best for him to leave his 8,000-square-foot home for assisted living accommodations. The option came in the form of a system that, when installed in his home, could provide a clear picture of his activities of daily living, known as ADLs.

Each day, medical professionals at The Oaks received a view of the man’s activities and, by doing so, could easily tell if anything had changed in both his habits and his medical status, such as weight and blood pressure. On three specific occasions, the system caught weight gain and enabled medical intervention to happen before his condition worsened to a point that it would send him to the hospital.

Eight years later, The Oaks is hoping to persuade the one hospital that serves its small town to use its technology to help cut down on the number of patients who are readmitted within 30 days of their discharge. Reverend James McGee, president and chief executive officer of The Oaks, says monitoring systems like theirs could play a significant role in reducing hospital readmissions and helping seniors in his small community to stay independent and healthy.

Some in the LTC industry admit that high hospital readmission rates are nothing new. It has always been an issue, but it has never been one that was systematically addressed by both LTC providers and hospital networks. That is, until October 2012 when Medicare began cutting payments to hospitals where too many patients were being readmitted within 30 days of their release for heart failure, pneumonia and heart attacks.

For the first time, LTC communities, hospital networks, physicians, policy makers and government groups are coming together to form solutions and prevent excessive readmissions, which was estimated to cost Medicare $4.3 billion in 2006 alone. Solutions are appearing in varying forms, from improved in-house communication strategies to comprehensive programs that equip LTC communities with numerous tools. The result is often the same: reduced readmissions and stronger, cohesive relationships between all healthcare providers.

Challenges still remain, but LTC providers are finding what path works best for them.


One of the first ways The Oaks responded to the new Medicare measures was to work with a local hospital and cardiologist to create a new protocol that staff could follow. Most of the individuals coming into The Oaks’ skilled nursing facility have been at the hospital for congestive heart failure. So, the community knew it had to make changes in order to avoid unnecessary transfers of these residents back to the hospital.

Protocol now requires staff to weigh residents at specific times each day, such as when they awake in the morning or before they eat a meal. The weight is recorded and it is immediately addressed any time a resident’s weight goes up by providing medication that decreases fluid retention. If such changes can be caught within 24 hours of when it happens it can drastically reduce the probability of that patient having to return to the hospital, McGee says.

“I know we have avoided at least three ambulance runs because of that,” he adds.

Meanwhile, the technology The Oaks used to monitor the man’s condition in 2005 seemed like a solution to address the issue with seniors living in their independent living settings as well as outside their communities.

The Oaks created several different monitoring systems including one called GrandCare and another called Touch Point Care. The systems record such data as weight, blood pressure, blood sugar and pulse oximetry. ADLs are detected through the use of motion sensors, floor pads and bed mats. The community currently has 60 individuals on its campus using the systems and another 10 in private homes around the community.

McGee says Orangeburg is a perfect place to offer such systems simply because of the make-up of its residents.

“We are in a 175-mile area where people are easily discharged from the hospital and they don’t have a primary physician,” McGee says. “They don’t have good transportation and they don’t have a set up at home to be able to adequately be taken care of.”


Beaumont Rehabilitation and Skilled Nursing Center in Westborough, Mass., has found that avoiding hospital readmissions is a group effort. The facility was one of 10 in its state to be the first to use a program called INTERACT, which stands for Reduce Acute Care Transfers. The program—developed by a geriatrician at Charles E. Schmidt College at Florida Atlantic University and funded by the Centers for Medicare & Medicaid Services—equips users with numerous tools that allow caregivers on all levels to effectively reduce readmission rates.

“When we went through training for INTERACT, it involved talking to residents, family members, and hospital and ER staff and physicians,” says Paul O’Connell, Beaumont’s administrator. “You realize that anyone can effect readmission to the hospital and we had to make sure that everyone understood what we were trying to do.”