By Laura Thill
Growing awareness on the part of post-acute-care facilities, together with financial penalties, are expected to continue to reduce hospital readmissions.
Organizations – from hospitals to post-acute-care organizations to medical products distributors – are doing their part to facilitate changes that reduce hospital readmissions. However, the approach to change varies from one organization to the next, making it more important than ever for stakeholders to understand the issues.
“There are several issues that post-acute care facilities face now – and certainly will face in the future – regarding hospital readmissions,” says Susan LaGrange, RN, BSN, NHA, CDONA, CIMT, director of education, Pathway Health. “For several years now, hospitals have been choosing their post-acute care partners and providers wisely, due to the financial consequences of readmissions within 30 days with certain diagnoses. Effective April, 2016, the Centers for Medicare and Medicaid Services (CMS) began posting data for six new Quality Measures, including the Percentage of short-stay residents who were re-hospitalized after a nursing home admission.” With Value Based Purchasing (VBP), organizations that have a high 30-day re-hospitalization rate (including observation stays) will face financial penalties, she adds.
Long-term-care facilities – long before they morphed into post-acute-care organizations – recognized the need for protocols designed to reduce hospital readmissions, but until now, their approach has varied. “Up to this point, there have been vast differences in how organizations have embraced the need for change,” says LaGrange. “Some organizations have been proactive by putting into place evidence-based standards of practice [designed to] keep the resident safely in the facility.” For instance, some programs provide front-line staff with resources and training to identify acute changes in a patient’s condition early on, she explains, allowing them to communicate more closely with the practitioner and better manage the patient’s treatment. That said, “there are some organizations that have yet to put into place an organized process,” she adds.
Moving forward
Readmission penalties – together with the changing mindset that providers must take steps to improve the quality and coordination of care from hospitalization through recovery – have led hospitals to change their discharge practices, according to experts. “I do believe that the readmission penalties have led to some improved discharge practices, including better communication of resident needs and stability of resident condition when discharged into the post–acute care settings,” says LaGrange. “In talking to providers across the country, [I see] there continues to be a good number of hospital discharges that occur on a Friday or Saturday, when the facility staff must talk to on-call physicians to clarify orders, or discuss unstable conditions, and these physicians are not always familiar with the resident. There may continue to be opportunities in this area on both sides – that of the hospital to ensure stability of the resident’s condition for discharge with good communication, and that of the post-acute care facility to prepare with a good pre-admission assessment process for a successful care transition.”
LaGrange predicts that post-acute-care facilities that closely consider “the culture of the readmission process, from admission through discharge, and collaborate with all entities the facility works with, as well as in-house systems” will be most likely to succeed at limiting hospital readmissions. This will entail the following, she notes:
- Communication with the acute-care provider is crucial to ensure that the resident is appropriate for discharge to the post-acute care setting and that the proper care and resources are ready for the admission.
- The organizational process and systems management in the organization are essential to be able to identify early changes of condition and a streamlined approach to the evaluation/assessment, communication and care management in the facility.
- Educate and train. Nurses require training on the assessment process, disease management and system processes for quality of care.
- Successful discharge planning should start on the day of admission.
- Follow up. It’s important to follow up on discharged patients to ensure the successful transition of care and assistance with management in a new setting.
Indeed, it’s essential that post-acute-care facilities collaborate and communicate well with acute-care providers, she continues. “The post-acute care provider could have a key clinical contact meet with the hospital discharge planning team to discuss opportunities for successful care transition and to include good assessment, preparation and communication of the patient’s needs and condition,” she says. “The biggest obstacles today revolve around time. Nurses (both acute care and post-acute care) face such challenges as time and inadequate staffing resources. Unfortunately, with Value Based Purchasing, the nursing home could face an even greater struggle with resources if quality systems are not in place and the readmission numbers are high.”
New post-acute-care protocols designed to reduce hospital readmissions are long overdue, notes LaGrange. “Studies have clearly indicated that a good number of hospital readmissions within 30 days of discharge could have been avoided,” she points out. “When good systems are in place for all sides of the care transition process, changes of condition are identified early and managed. This provides for quality of care for the [patient], while saving tax payer dollars at the same time.”