The race to reduce hospital readmissions

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.”

One of the INTERACT tools is called a STOP AND WATCH card, which acts as an acronym for different behaviors or medical changes that, if different than normal, may signal that attention is needed. For instance, S stands for “seems different than usual”, T stands for “talks or communicates less than usual” and so on. The card can be filled out by family members, orderlies and medical staff. Every STOP AND WATCH card is evaluated and the nurse who processes the concern is required to bring closure to it.

INTERACT’s SBAR (situation/background/assessment/request) communication tool empowers nurses to make more accurate recommendations when communicating with hospitals. Physicians can best determine if residents actually need to be transferred back to the hospital if the nurse has all the facts at hand when the call is made. SBAR provides all the information a nurse needs when calling into a hospital about a patient.

Hospital readmission is not just an issue for medical staff. Beaumont has educated loved ones about its goals to cut down the amount of people who return to the hospital so they can re-evaluate whether their request to have a family member hospitalized is necessary. These changes have brought significant results: the center has seen its hospitalization rate fall by 72 percent since it adopted INTERACT. In 2009, the facility’s rate was 2.16 hospitalizations per 1,000 residents. Today, its rate is below .58 hospitalizations per 1,000 residents, O’Connell says. 


Hebrew SeniorLife, Boston, Mass., has full-time medical staff on-site, which, it says, plays a significant role in lowering readmission numbers. Staff can have the attending physician evaluate a resident at any time of the day, which takes the guesswork out of whether the resident requires a trip to the emergency room.

“Our community is unique,” says Fred Rowland, PhD, MD, interim medical director. “We have nurse practitioners and physicians working on all units and we’ve created a system to increase communications between them. We have created things like structured sign-in and sign-out so there is clear communication between nursing staff and the issues that they are identifying on patients and our residents. We also make sure that what a patient needs is addressed that day.”

Hebrew SeniorLife developed a program called Team Improvements for Patient Safety (TIPS), which provides an opportunity for staff to re-evaluate readmissions in a non-judgmental setting to determine how it can be avoided in the future. Rowland says TIPS has made a significant difference. One unit saw readmissions drop by up to 40 percent through use of the program.

The community also utilizes other tools including KNOW IT ALL that was put out by the American Medical Directors Association (AMDA). The tool empowers staff with all the appropriate knowledge they need about a patient to make decisions and to adequately communicate a resident’s condition to hospital personnel.

Rowland says better communication means less resident transfers, which can have a significant impact on individuals who are frail and cognitively challenged. A simple transfer to the hospital exposes aging individuals to new environments which can add issues like delirium on top of the acute illness that is being treated.

So, what then, has been the root of readmissions over all these years? Dr. Rowland says it’s a combination of many factors.

“Many nursing homes don’t have physicians who will come running when they call, and even when they do it may be a covering physician who is called in the middle of the night and doesn’t really know the patient they are evaluating,” Dr. Rowland says. “There have been times [in the LTC industry] when if the staff is in doubt the answer was to send the resident to the ER to be evaluated.”

Rowland says the answer is more on-site physician involvement, but that’s not a reality for many small communities. Moreover, it’s an increasing challenge for the industry, which has always struggled to attract physicians to work in its setting. Still, the fight against readmissions isn’t hopeless. LTC operators are poised to play a big part in turning around the trend of high hospital readmissions with the ever-increasing tools and support continuing to be generated by the innovative within their own industry.

Julie Thompson is a freelance writer based in Dayton, Ohio.

Topics: Articles , Clinical , Executive Leadership , Facility management