OpenPlacement Blog

Reducing Readmission from Long Term Care Facilities

Earlier this month, we offered some Strategies to Reduce Readmission and got a very positive response from readers. So, we've decided to expand on our tips and strategies and to provide some specific advice for lowering readmission strategies when releasing patients into specific post-hospital environments. Since so many patients go to long-term care (LTC) facilities after leaving the hospital, we'll be starting with some tips to reduce readmissions when patients are released into a long-term care situation.

Tips for Reducing Readmissions from Long Term Care

Long-term care facilities are staffed by medical professionals so in many ways it should be easier to avoid readmission when a patient is released to a facility rather than sent home. Unfortunately, due to a variety of problems including inadequate communication with long-term care facilities; choosing the incorrect facility; and overstaffed and underperforming long-term care providers, readmission rates still remain stubbornly high. In fact, according to the Robert Wood Johnson Foundation, approximately ¼ of Medicare beneficiaries discharged into a skilled nursing home were readmitted to hospitals within 30 days, at a cost of $4.34 billion.

A number of different techniques should be considered to try to reduce the readmissions rates, and Hospitals & Health Networks provides a list of several steps that hospitals and nursing homes should try. Some of these steps include:

  1. Hospitals assisting LTC facilities in improving the management of care. 

Many long-term care facilities simply do not have the staff or the experience to institute a rapid improvement in how care is managed.  In fact, according to Medicare, studies have shown that improving nursing home staff can create a significant reduction in readmission rates. While LTC facilities would have to make the decision to hire new staff on their own, including an on-staff physician or nurse practitioners, hospitals can still do a lot to assist LTC facilities. For example, Hospitals & Health News Networks advises hospitals to assign nurse managers to facilities that accommodate many discharged patients.

  1. Hospitals assisting LTC facilities in streamlining processes and avoiding care delays.

One proposed suggestion for improving the quality of patient care, reducing care delays and reducing readmission rates is to make use of the Stop and Watch Tool. The Stop and Watch Tool is explained in a 2011 article on reducing hospital readmissions( hospital readmissions.pdf) produced by the TMF Health Quality Institute: Jennifer Markley, RN, BSN, Senior Director For Quality Improvement; Cindy Bigbee, RN, MSN, Quality Improvement Consultant; and Linda Whitmire, Communications Specialist.  The Stop and Watch tool is a system that makes it easier for nursing home care providers to keep track of a patient's condition and to report any potential problems.

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The Stop and Watch System may be a method of streamlining how care is provided, avoiding care delays and catching problems early before they lead to a readmission.

  1. LTC FacilityImproving communication between hospitals and care facilities

A September 2010 report by the Congressional Research Service indicated that many patients are sent back to hospitals by LTC facilities because there is insufficient information provided about the care needs of the patient. Becker Healthcare's Hospital Review suggested making sure discharge plans are communicated directly to the skilled nursing facility, rather than to the case manager who passes the information along to the facility. Multiple visits to the patient from a physician should also be planned during the first few weeks of a transition.

  1. Adopting low-tech workarounds to make the exchange of crucial information easier until high-tech solutions become available

Hospitals & Health Networks indicates that something as simple as printing out the continuity of care document can make a difference in reducing readmission rates. The Becker Healthcare's Hospital Review also advises making sure the discharge note is tailored to the received. When the patient is going to a long-term care or skilled nursing facility, therefore, it should include information on mental status, IV medications, infections, and the names of outpatient providers. The more information the LTC facility has and the easier it is to access the information, the better the chance of success.

  1. Forming stronger partnerships between LTC facilities and hospitals

Both hospitals and long-term care facilities need to work together to find solutions to avoid readmission. Hospitals need to choose the right facility for the right patient and both hospital and LTC home need to be committed to preventing a readmission through appropriate post-release care.

About the Author

Christy Rakoczy has a JD from UCLA School of Law and an undergraduate degree in English Media and Communications from University of Rochester. Her career background includes teaching at the college level as well as working in the insurance and legal industries. She is currently a full-time writer who specializes in the legal, financial and healthcare sectors. Ms. Rakoczy writes online content as well as textbooks for adult learners.