Solving the readmission rate puzzle

The monumental task of reducing unnecessary hospital readmissions—and the back-and-forth passing of residents between skilled nursing and the emergency department (ED)—requires diligent nursing documentation, access to the right technological tools at the right time and a growing acceptance that acute care and long-term care are partners in it for the long haul.

The stats from reports are startling:

  • The annual cost of readmissions to Medicare is approximately $17.5 billion, as of early 2013.
  • Almost half (45 percent) of hospital readmissions among Medicare beneficiaries could have been prevented with well-targeted interventions [Health Affairs, 2013].
  • Nearly 25 percent of nursing home residents are sent to an ED annually, yet almost one-quarter of those transfers could have been prevented.
  • Yes, the problem is bi-directional: 30 percent of people who are discharged from a hospital to a skilled nursing facility (SNF) are experiencing at least one medical error, often including medications, according to an article listed by the National Institutes of Health. Many of those residents could end up back in the hospital later, if interventions are not noticed and performed in time.

The messy gamuts of care transitions—and the documentation processes they entail—are crucial to tackling the readmissions problem, explained James E. Lett, MD, CMD, in a webinar Wednesday hosted by the National Transitions of Care Coalition (NTOCC).

Although hospitals took the first brunt of the penalty wave from the Centers for Medicare & Medicaid Services (CMS) for unnecessary readmissions for certain conditions, long-term care is now clearly part of the regulatory equation: CMS has proposed to bring long-term care (LTC) facilities into the penalty mix for certain conditions under its April 2014 bill to add long-term care to the accountability mix, with the resulting data to be reported on the Nursing Home Compare site as early as 2015.

So what is the “right” target rate for readmission? It’s still a bit of a disconnect nationally, noted Lett, a member and past president of AMDA—The Society for Post-Acute and Long-Term Care, who also served as a member of the CMS workgroup to revise F-Tag 329: Unnecessary Drugs. “No one seems to know what the ‘right’ 30-day readmission rate is. But we’re going to continue to get pressure to reduce our readmission rates,” he said. “In the LTC world, there’s certainly evidence that readmission rates can be reduced with well-targeted interventions.”

The concept of shared responsibility is here to stay, as is evidenced by CMS’ multi-year, warts-and-all foray into accountable care organization (ACO) models. Among them, two of the current ACO models already specifically involve the LTC part of the care continuum (models 2 and 3). For LTC organizations: “If you’re not involved in one of these ACO models already, you probably will be approached about it [by potential hospital partners] in the future,” Lett said. “It’s something you need to know about.”

Key target areas have been identified as crucial to reducing readmission rates coming from skilled nursing environments, and none of them are quite as easy to deal with as they sound, Lett added.


  • Documentation, especially for change of condition: Detailed tracking for change of condition can bypass many unnecessary readmissions, but only if the documentation on intake is equally detailed and timely. How/when do attendant caregivers know when to intervene with a clinician before a clinical condition escalates to a readmission? “Everyone needs clearly assigned roles and accountability,” Lett said. “Who completes the forms? Who has the up-to-date list of family members? If you have a bad process, the best forms in the world won’t overcome that. Don’t confuse paperwork with communication.”
  • Medication management: According to a February 2014 report from the Office of Inspector General, of all residents transferred from a SNF to a hospital, 22 percent had adverse drug events, and more than half of those events were deemed preventable. “Forty-six percent [of those adverse events] are [deemed] likely preventable, and 13 percent should have been no-brainers. Those are hard numbers,” Lett said. The problem of polypharmacy is growing hotter as a topic for caregivers at all levels. SNFs should never assume that the meds a resident came in with are applicable forever, and likewise, hospitals and SNFs need to communicate better on what meds should be continued after discharge, Lett said. When it comes to the older population, most of whom are on at least four different medications, “When there’s a problem, the first three things you should think about are medications, medications, medications,” he added.
  • Communication with acute care: Nothing can replace good relationships among caregiver in skilled nursing organizations and their acute-care partners, Lett stressed. As one example, as many as two-thirds of residents sent to an ED have cognitive impairments, Lett said. “The ED really depends on us [in LTC] for providing resident information, and we’ve got to do better.”


Yes, new rules are coming that may help reimburse LTC facilities for doing the transitions-of-care processes right. In the meantime, initiatives at the SNF level can always be approached as quality initiatives, Lett suggested. “Using it as a quality assurance improvement project is a great way.”

Among the national prompts to encourage SNFs to engage are the national ACO programs, the Hospital Readmission Reduction Program and the “bundled payments” options available under “episode of care” agreements with hospitals, Lett said. Many projects are already under way among many skilled nursing organizations, including INTERACT, Project RED and Project BOOST, Lett added.

For reference: AMDA also offers its own tools for better care transitions on its website at

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