Reducing hospital readmissions has been the focus of many government agencies, including the OIG, which identified hospitalizations of nursing home residents as a focus area in its 2013 Work Plan. As stated in the 2014 OIG Work Plan, the plan aims to "determine the extent to which hospitalizations are a result of manageable or preventable conditions." In addition to often being deemed unnecessary, re-hospitalizations have been recognized as a significant cost to Medicare. The Affordable Care Act established the Medicare Hospital Inpatient Readmissions Reduction Program, which creates financial incentives to reduce preventable readmission rates by penalizing hospitals with excessive readmissions. The program identifies three diagnoses of focus for 2013: Acute Myocardial Infarction, Heart Failure, and Pneumonia. Furthermore, in March 2012, the Medicare Payment Advisory Commission (MEDPAC) reported that it has recommended reducing payments to skilled nursing facilities (SNFs) with relatively high rates of re-hospitalizations. Avoidable re-hospitalizations of SNF residents increase Medicare spending, expose beneficiaries to additional disruptive care transitions, and can result in hospital-acquired infections or other adverse health consequences.
Know your statistics
To begin the process of reducing hospital readmissions at your facility, find out where your facility stands. The American Healthcare Association (AHCA) has a Long Term Care Trend Tracker Tool that allows facilities to compare their re-hospitalization rates to other facilities across the nation. The tool is located here. Collect internal statistics by reviewing resident discharges for the last 180 days. Look at factors that could contribute to a hospital readmission, such as reasons for discharge and dispositions, primary diagnosis and comorbidities, lengths of stay, ER visits during stay, and other contributing factors, such as family dynamics. By reviewing this type of information, trends may be identified that could help to prevent unnecessary hospital readmissions in the future.
Evaluate Your Operations
After considering past hospital readmissions trends, evaluate your facility's operations to see what needs to change in order to facilitate a reduced number of hospital readmissions. Consider some of the following practices in your facility:
1. Evaluate your pre-admission process.
- Does your facility take steps to ensure that it only admits residents that it can adequately care for?
- Is the Director of Nursing Services empowered to control the acuity of the resident population at the facility?
- Does your facility conduct on-site assessments (versus telephone reviews) prior to admission?
- Are discharge goals understood prior to admissions?
2. Evaluate the competency of the facility's nursing staff.
- Are staffing rotations arranged so that there is an equal competency level on all shifts?
- Is the nursing staff appropriate for the case mix?
3. Evaluate discharge planning and post-discharge follow up procedures.
- Are discharge care plans initiated upon admission and completed upon discharge?
- Are residents discharged with a full understanding of their medications and do they have adequate access to their medications?
- Is any type of follow-up communication scheduled with the residents after they leave the facility?
4. Be proactive
- In the event of a change of condition, nursing staff should present a thorough assessment to the resident's physician, so that the physician can be confident in the facility's understanding of the resident's condition and give orders to provide the best care for the resident.
- The Director of Nursing Services should keep a list of the residents at the highest risk in the facility, and all staff should be aware of residents with special care requirements.
- Implement all nursing interventions relevant to the residents' conditions, with adequate assessments prior to transferring residents to the acute.