Communication and collaboration are the keys to reducing patient rehospitalization. Studies suggest that healthcare professionals, including physicians, hospital leadership, and assisted living or skilled nursing facility administrators, can avoid unnecessary and costly readmissions by working together.
Although predicting which patients are at risk for readmission is not an exact science, there are some concerns cited by patients themselves that healthcare professionals have begun addressing:
- Feeling unprepared for discharge
- Difficulty performing activities of daily living
- Trouble adhering to or difficulty accessing discharge medications
- Lack of social support
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10 Strategies for Reducing Hospital Readmissions:
- Quality first. It’s simple, but true. Care for patients correctly and:
Begin care management and discharge planning early. Keep the flow of communication going across the coordinated care team, including family members, primary care providers and staff at the patient’s ALF or SNF. Make post-discharge appointments for follow-up care before patient is discharged. Make post-discharge phone calls soon after discharge, so a team member can assess the patient’s condition and answer questions.
Review medications face to face. Physicians caring for the hospitalized patient should review all of the patient’s medications and give the patient clear, explicit instruction on how to properly take them.
Use teach-back techniques to ensure patient education. Educate patients and their families in managing the health condition, but at a level appropriate to them. Ask patients to “teach back” or explain the information they’ve been given.
Use health information technology. Barriers exist that make it difficult for primary care physicians (PCPs) to help manage the handoff from the inpatient to outpatient setting. With a universal health record, the PCP can easily and quickly find out what transpired in the hospital.
Enhanced training for SNF/ALF staff. Assisted living and skilled nursing facilities that provide training to their clinical staff reduce hospital admission and readmission rates. A training program should be implemented to help staff identify and address early changes in a resident's health ad mental/functional status.
“SNFists.” The availability of physicians, nurse practitioners or physician’s assistants on-site to perform an immediate assessment of acute changes in the clinical status of skilled nursing facility residents is invaluable to avoiding unnecessary hospitalizations.
Community paramedicine. Community paramedicine can be a good fit in a hospital’s overall plan to reduce readmissions, particularly in rural or under-served areas. Emergency Medical Services are already established in communities. With extra training, paramedics can expand the scope of their practice to provide home visits and health services to patients at risk for readmission.
Advance directives. Knowing what care patients want at the end of life can provide treatment direction, options and choices when a patient has a change in healthcare status. Patients often prefer the option of staying in place rather than going to the hospital. Advance directives should be documented and on file so the clinical staff and physician know the patient’s wishes.
Palliative care and hospice. For appropriate patients, hospice and palliative care offer a more dignified and comfortable alternative to spending their final months going back and forth to a hospital. Hospice provides care to patients in their homes—whether the home is a private residence, an assisted living community or a skilled nursing facility. A hospice team of physician, nurse, aide, social worker, chaplain and volunteer manage the patient’s pain and symptoms and give social, emotional and spiritual support to the patient and family.
- readmission rates fall
- performance on quality measures improves
- savings are realized