Rehospitalization: What it Means for Your SNF and How You Can Avoid It

Rehospitalization: What it Means for Your SNF and How You Can Avoid It

Have you been through the cycle of admitting a discharged-from-the-hospital resident to your facility only to walk them through the re-hospitalization process 7, 10, or even 30 days later?

Unfortunately, the circular route from an Acute Care facility to a Post-Acute Care facility and back to the hospital again is an oft-repeated one. It’s one that is the root of much aggravation for all involved parties. Unbelievably, it is estimated that as many as 60% of these occurrences are avoidable.

This should be reason enough for a savvy nursing facility administration to explore the realities of, impact on, and helpful tips to avoid re-hospitalization.

The Effect on SNFs

For many, increased re-hospitalization rates are the cause of much lost revenue. As a nursing facility, these rates are a vital metric on which  you should monitor and work to decrease.

Since they began to be penalized for increased 30-day readmission rates, hospitals have expended much effort to reduce these occurrences. Currently, Post-Acute Care facilities are being motivated to get patient readmission rates lowered, and ultimately avoid financial and technical consequences.

The Financial Impact

  •      Penalties – Higher-than-expected re-hospitalization rates within a 30-day period are penalized with a potential 2 percent reduction in Medicare payments.
  •      Referral Decrease – Underperforming centers usually suffer from a decrease in referrals from hospitals.
  •      Lowered Ratings – Nursing facilities are required to submit their 30-day readmission rate data, which can result in a loss of referrals from patients and families who use the publicly available data to make decisions about where to receive continued care.
  •      Increased Costs – From the additional medical care necessary for patients who were not provided with the best care preceding their readmission.
  •      In Numbers – After the SNF Value-Based Purchasing Program was implemented, CMS data showed that 73% of the 14,959 skilled nursing facilities subject to the program were penalized for poor 30-day readmission rates in 2019!

Tackling Re-hospitalization

1. Meticulous Patient Evaluation

With hospitals keeping patients for as short a stay as possible, many are discharged with medical needs that must be carefully treated at a Non-Acute facility. Therefore, a proper patient assessment must be conducted. One that involves studying the patient’s medical records and history, including all diagnoses, comorbidities, labs and diagnostic test results, physician orders, medications, and required therapies. Thus, the continued care can be as seamless and effective as possible.

2. Care Organization

The CMS requires that a written care plan be drafted within 48 hours of admission to an SNF. The care plan should describe the patient’s treatment plan and include a readmission risk evaluation based on their medical condition.

Clinical risk factors should also be considered, and an increasing amount of facilities offer services like IV medication and proper nutritional guidance to resolve all factors in time.

3. Timely Intervention

With many patients admitted with complex medical conditions, their health can deteriorate at a quick pace and give way to a – possibly preventable – return to the hospital.

That being said, more vital sign monitoring, on site labs, and Telemedicine is being made available within facilities. This allows for swifter turnaround, which often means detecting changes in patients’ conditions early on.

4. Coordination of Care

Medical research continuously presents a correlation between avoidable hospital readmissions and poor coordination among providers. When a patient is discharged from a hospital and admitted to a nursing home, the transfer must be executed properly to reduce the chances of a preventable readmission. When improperly handled, the chances of returning to the hospital are a lot greater.

For example, a great place to start is by focusing on medication reconciliation. Knowing which medications patients were taking before they were admitted to the hospital, were taking in the hospital, and what was prescribed upon discharge (which can be tracked using digital tools), can also mitigate these return trips.

Overall, effective communication between all providers and healthcare organizations, including hospitals, doctors, and pharmacies, will go a long way to ensure patients receive the best possible care on-site and decrease readmission rates.

5. Staff Efficiencies

The right staff is crucial to carrying out the above suggestions. Although there may be increased cost, facilities must ensure employees hired excel at implementing them.

You may want to ask yourself the following questions:

  •       Can employees properly and thoroughly assess the health and readmission risk of patients?
  •       Can a care plan be drafted and executed by staff members?
  •       Can diagnostic skills in combination with medical technology be utilized to notice changes in patients’ conditions as early as possible?
  •       Can employees use both personal and digital devices to drive care coordination?

In general, having staff members do their part by getting recommended vaccines and seasonal shots to prevent communicable diseases, and ensuring they adhere to infection control protocols such as proper hand hygiene, can go a long way in preventing unnecessary complications which lead to re-hospitalization.

A Win For All

Yes, these implementations may be costly. But, if readmission rates are thereby lowered, the return on investment will likely exceed these outlays.

Because, after all is said: decreasing re-hospitalization is costly, yet increased re-hospitalization is costlier.

And the primary goal – optimal patient care – can only be enhanced by actively working to decrease those return trips to the hospital.

Here’s to a win-win.