Proactive strategies to reduce hospital readmissions

Skilled nursing providers (SNFs) are all too familiar with the challenge of preventing hospital readmissions for residents. It’s hardly a new issue but in recent years it has come to the forefront of the national healthcare reform conversation.

Providers also know that readmissions can be traumatic for residents and their families and in many cases unnecessary. Customer satisfaction and confidence plummets with disruptive transfers back to the hospital.

Several driving forces are pushing hospitals to re-evaluate their strategies to identify high-performing partners in the fight against readmissions. Hospital revenues depend on it and so does SNF revenue, as hospitals will award referrals to post-acute partners who are aligned in the fight against avoidable hospital readmissions.

In a recent Long-Term Living webinar that addressed this very issue, Maria Arellano, MS, RN, Clinical Product Manager, American HealthTech, reviewed the scope of the challenge and offered proactive strategies for providers to consider in their continuing quest to reduce hospital readmissions.

The reasons for readmission involve a decline in the resident’s clinical condition and encompass four shortcomings, says Arellano: failure to recognize decline, prevent complication or poor quality of care; poor transitions of care/discharge planning; a lack of an advance directive; and/or an inability to meet the needs of the resident (perceived or real).

“Our bottom line goal is to eliminate the preventable rehospitalizations by preventing the clinical issues that cause them,” says Arellano.


Where to start? Consider a retrospective review, suggests Arellano, including:

  • A look at discharges to the hospital over the last 180 days. Analyze the reason for discharge and disposition.
  • Primary diagnosis and comorbidities
  • Length of stay
  • Time/day of week of discharge and discharging nurse/ER visits during the stay
  • Contributing factors, such as family dynamics.

Next, evaluate the pre-admission process, recommends Arellano. “Are you taking admissions that you have no business accepting?” she asks. “Are you receiving adequate information about potential residents’ needs? The admission process is lengthy and complicated; allow enough time or enough resources.”

Advance directives should also be considered. Arellano says it’s more than just a “yes or no” to cardiopulmonary resuscitation (CPR). Know your state-specific requirements and obtain directives upon admission, if not before.

“Getting residents and/or family members to discuss advance directives is tough,” says Arellano. “Let’s face it, it’s an emotional discussion and not everyone will come to your facility with everything in place. There’s always a lot of discussion about whose role it is to obtain this. [Is it the] role of the social worker? Nurse? Maybe it’s a team approach.”

Other areas to review include nursing staff competency, medication management, nursing assessments and communication, and discharge planning/transition of care. “Start discharge planning before they come in the door, says Arellano. “What needs to happen to achieve this goal? Discuss it with the family and potential resident. Discharge planning is a process; it includes home evaluation.”


Consider adding a new dimension to your services with a post-discharge program, suggests Arellano. For example, schedule a follow-up phone call within 48 hours of discharge to troubleshoot any problems. Phone with a reminder of a follow-up doctor appointment, and check on the resident again 30 days after discharge.

Finally, consider the benefits of an electronic medical record, says Arellano, for simplified data aggregation and clinical decision support. The key metrics hospitals want to see include: rehospitalization rates, Nursing Home Compare Quality Measures and five-star ratings, average length of stay by diagnosis, annual survey results/complain investigations and clinical outcomes.

To obtain a copy of Arellano’s whitepaper, “15 Ways to Attack Readmissions,” click here.

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