Assisted Living Program for Reducing Rehospitalizations Could Have National Impact

Brookdale Senior Living, the nation’s largest provider of senior-related services, has received federal funding through its partnership with the University of North Texas Health Science Center for an initiative to do what many assisted living providers are seeking to accomplish: reduce hospital readmissions and provide a better quality of care for residents.

Avoidable rehospitalizations cost Medicare upwards of $17 billion a year, the Centers for Medicare & Medicaid Services (CMS) estimates. In an effort to find—and fund—ways to provide better, more cost-effective care, the Department of Health and Human Services launched the Health Care Innovation awards, which made nearly $1 billion of grants available to healthcare providers with plans to improve care while saving Medicare money.

Transitions of Care program


About half of readmissions from skilled nursing facilities back to hospitals are preventable with timely intervention, says Dr. Kevin O’Neil, Brookdale’s medical director, and that’s where BSL Transitions of Care comes into play.

“When someone moves from one venue of care to another, especially for older adults who may have multiple medical issues, it often results in things falling through the cracks,” O’Neil says.

This could be for a variety of reasons, ranging from medication not being coordinated or administrated properly, to problems related to communication between the hospital and the post-acute care provider, he says.


“One of the big areas of focus [of healthcare reform] has been the number of folks who end up going back to the hospital because of those kinds of issues,” says O’Neil, citing statistics that 20% of Medicare patients that get discharged end up being rehospitalized within 30 days.

The Transitions of Care program hinges on an evidenced-based assessment tool called Interventions to Reduce Acute Care Transfers (INTERACT) along with health information technology resources to help senior living communities identify, assess, and manage residents’ clinical conditions to reduce preventable hospital admissions and readmissions.

It works by helping staff manage changing conditions in patients, says Dr. Joseph Ouslander, a professor of Clinical Biomedical Science and associate dean for Geriatric Programs at Florida Atlantic University, and one of the INTERACT tool’s main developers.

Prior to receiving a $7.3 million Health Care Innovation award from HHS for applying the Transitions of Care program to assisted living and home health settings, the Brookdale/UNTHSC partnership had already been with working with Ouslander to implement the program into some of Brookdale’s skilled nursing facilities.

The provider’s goal was to reduce those 30-day hospital readmissions by 20% in the next 10 to 12 months, says O’Neil, especially for heart failure—one of the top reasons people discharged to skilled nursing facilities end up getting rehospitalized.

In the first year, the community testing the program had zero readmissions for heart failure.

Applying the program to assisted living

Based on those results, says O’Neil, Brookdale started expanding the program to several other sites. Then they started thinking about expanding the program to different settings, as well.

“It’s very exciting,” says Ouslander of the federal grant for the Brookdale/UNTHSC initiative to introduce INTERACT into assisted living settings.

“The main purpose of this whole grant is to refine the INTERACT program so it can be used in assisted living and in home health, so that it can be used across different settings or capabilities,” he says.

The principles of the program are those of quality improvement and good care of older people who have a changing condition, says the INTERACT developer.

“Someone at an assisted living community may see a resident is losing weight, or not eating well, or coughing more,” says Dr. Jose Pagan, Ph.D, chair and professor at the University of North Texas Health Science Center. “This set of tools allows you to track that, so that information is reported quickly and something is done about it.”

The program uses a Clinical Nurse Leader (CNL) to gets the community’s entire staff on board—not just the nurses or clinicians—to report residents’ conditions and ensure they receive appropriate attention and care.

Brookdale and UNTHSC estimate the program will reduce hospitalizations in a way that could save the Medicare program $9.3 million—and that’s a conservative estimate, says Pagan.

Will the program be successful?

However, outcomes won’t necessarily match up to those seen in the skilled nursing settings, as assisted living has a different resident census compared to nursing homes, and staffing differs between the two models.

“You can’t expect a skilled nursing facility to give the same clinical care as in a hospital, and it’s the same for this,” says Ouslander. “You can’t expect an assisted living community to give the same care as in a skilled nursing facility. That’s unreasonable—and it could be unsafe.”

The question, he says, is what’s realistic to implement in an assisted living setting, given staffing.

“I don’t know,” he admitted. “We’ll find out.”

If the results are successful, though, the impact could be far-reaching.

“We intend to share this [model of care] with other post-acute care providers,” says O’Neil. “Nothing we put together is proprietary.”

“This goes beyond Brookdale,” confirms Pagan. “If it works with Brookdale, others can learn from it and implement it in their settings. The final goal for this is to have a very broad impact.”

Written by Alyssa Gerace

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