Medicare program to cut down on hospital readmissions, add to nursing home workload | I Advance Senior Care Skip to content Skip to navigation

Medicare program to cut down on hospital readmissions, add to nursing home workload

April 15, 2009
by JRosenfeld
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The Care Transitions Project is a new Medicare program intended to reduce the number of people who are readmitted to hospitals shortly after their discharge—and ultimately save the agencies money. Presently, many nursing homes and assisted living facilities are faced with the difficult task of caring for people who may be recovering from an injury or disease that required hospitalization. In some cases, staff in the new environment are not trained on how to provide proper follow-up treatment.

The lack of staff training can translate to more visits to the hospital. By CMS's estimates, 20% of hospital patients get readmitted within 30 days of their discharge to a nursing home or assisted living facility. CMS estimates up to 75% of the readmissions are preventable with proper treatment in their discharge setting.

The program identified as the Care Transitions Project will be tested in 14 preselected communities. State officials will help facilities create programs to provide necessary care outside of a hospital setting. The program will begin shortly and will remain in place through the summer of 2011.

I hope this program has sufficient safeguards to ensure the safety of new admissions to nursing homes and assisted living facilities. Many people are at heightened risk for injury and disease shortly after their admission because their medical condition is unstable and the facility remains unaccustomed to their medical needs. Safeguards should be in place to ensure those who really need hospital services receive the care they require.

Lastly, at a time when budgets and services are already stretched thin, do we really want to add more to the list of responsibilities imposed on nursing homes? Jonathan Rosenfeld is a lawyer who represents people injured in nursing homes and long-term care facilities. Visit his personal blog at


Jonathan Rosenfeld...



what I have the most problem with is residents comeing back from the hospital and the paper work being blank(SMS). This leads to a phone call to get the doctor who discharged the patient to confirm the medications. The in turn assumed that the nurse on the floor had filled out the paper work before the patient was sent back. This is especially hard on the weekends whe the physician has usually left the hospital and may not be the doctor that is on call. We have mad e a rule that patient must be sent to us during hours when my self or one of my other RN's is in the building. The RN also does a head to toe assessmet on the resident to identify any skin issues that we aquired while in the hospital.

Almost all nursing homes have sub acute units to treat the residents newly admitted to the facility r/t recent surgery or illness and are very well trained, their reputation depends on it. However, the nursing facility does not have the funds to provide increased staff for those residents that should have remained in the hospital nor the diagnostic equipment in-house for immediate testing hence the lower cost of nursing home care versus hospital care.
Nursing homes continue to admit residents that only a few years ago may have been on an ICU unit. The hospital should be held responsible for closer screening of patients before discharge rather than making it appear it is the nursing home's failure to provide care. They should also be held responsible for the hospital's failure to provide significant information regarding the resident's health status, such as presence of wounds and infections.

As a nursing home resident I have seen many instances in the past few months of hospital patients being prematurely admitted to this nursing home. Then they are required to be readmitted to the hospital. I don't know whether they are not being evaluated properly. But I certainly know that the hospital probably can no longer receive payment for their care and so they are discharged to the nursing facility.

To me it seems like a form of patient dumping like that which has occurred at skid row in Los Angeles. A nursing home is at least a warm environment. But many times patients are admitted who require much more care than the nursing home can provide.

I hope this Medicare program will help will help those on Medicare. But will anything help those patients who have only Medicaid?