Nursing Homes Play Key Role in Reducing Preventable Rehospitalizations

Unnecessary rehospitalizations cost Medicare millions of dollars each year, and with many seniors cycling from hospitals to skilled nursing facilities and back again, it’s paramount for nursing homes to figure out how to reduce readmissions.

As many as 60% of these rehospitalizations are preventable, writes Forbes, and they cost taxpayers millions of dollars each year. Health care reform has put a large focus on hospitals cutting their readmission numbers—starting in October, their Medicare reimbursements will reflect their performance—and it’s in nursing homes’ best interests to figure out how they can help. 

…[N]ursing facilities and their partner hospitals are taking steps to cut these readmissions. In researching a new article for the journal Health Progress, published by the Catholic Health Assn., I had the chance to visit and talk to some of the nation’s most creative senior service providers. And I learned about both the challenge of reducing hospital readmissions and some cutting-edge solutions.


Some of these initiatives are being driven by new Medicare rules. Among them: On Oct 1, Medicare will begin cutting payments to hospitals where too many patients are readmitted within 30 days of discharge. While the initial penalties are relatively modest and for only three conditions—heart failure, pneumonia, and heart attacks—they will gradually stiffen. And the new rules seem to have changed the mindset of many hospital administrators.

Increasingly, hospitals are improving discharges and keeping a close eye on patients after they leave. No longer do they abandon their patients once they roll out the front door. Many are putting transition programs in place—often using care managers, social workers, or nurses—to assist patients who are discharged to home. And slowly, they are beginning to work more closely with nursing facilities—both skilled nursing and long-stay nursing homes—to reduce readmissions.

At the same time, the best nursing facilities are making big changes of their own. They include:

  • Increasing staff and improving training for nurses and aides to help them identify and treat situations that can lead to hospitalizations. At Wheaton-Franciscan Healthcare in Wisconsin, nursing facility aides are trained to identify warning signs in heart failure patients and how to communicate what they see to staff nurses. These steps often prevent a crisis before it occurs.
  • Working with primary care doctors to encourage them to allow the nursing facility to treat many acute episodes rather than ordering patients back to the hospital.
  • Asking patients, residents, and their families whether they want to be hospitalized. When Hebrew Senior Life asked patients at its post-acute care nursing facility in Boston what they wanted, it discovered many preferred to stay where they were. Now, the HSL system is expanding this program to residents of its long-stay nursing home.

Nursing home trade group the American Health Care Association has challenged its members to reduce rehospitalizations 15% by 2015, and the Centers for Medicare and Medicaid Services has its own initiative to reduce avoidable hospitalizations from nursing facilities by funding organizations that partner with nursing homes to enhance on-site services and supports to residents and ensure a healthy, safe transition from the hospital. 

Read the full article at Forbes

Written by Alyssa Gerace

Recommended SHN+ Exclusives