Fla. Senior Care Community Partnership Results in Zero Rehospitalizations

Senior care providers looking for ways to improve care and outcomes for their residents in order to reduce unnecessary hospitalizations and readmissions may want to consider what one Florida full-service retirement community has done to generate readmission rates far below the state average.

A ten-year partnership between a West Palm Beach, Fla. community’s skilled nursing facility, Lourdes-Noreen McKeen Residence, and Evercare, a provider of nurse practitioners specializing in geriatric and nursing home care, has resulted in drastically reduced rehospitalization numbers. 

There were zero readmissions from residents participating in the community’s partnership with Evercare, while residents not enrolled in the program had a 4% readmission rate—significantly lower than the state’s average rate of 8.2%.


Through the partnership, nurse practitioners are on-site Monday through Friday and are available to answer questions from LNMR’s nursing staff, says Joy Brown, the facility’s director of nurses. The nurses are trained to conduct assessments on residents and gather data using certain forms that can help guide decision-making for patient care.

When it comes to senior care, many emergency room visits and a significant chunk of rehospitalizations could be avoided if discharged patients receive proper outpatient care in appropriate settings, according to a study recently released by the Medicare Payment Advisory Committee (MedPAC).

Lourdes-Noreen McKeen Retirement Community offers independent living, assisted living, and skilled nursing and has a more medical-intensive care model than some senior care communities. The skilled nursing facility can provide IV therapy and medication as well as treat certain respiratory or cardiac issues, says Brown. 


There’s less need for LNMR residents to go to the emergency room because of the nursing staff’s ability to conduct assessments and access the expertise of nurse practitioners. Rather than be hospitalized, residents can be treated on an outpatient basis in non-emergency situations as appropriate, Brown says. Additionally, medical professionals such as dermatologists, eye doctors, dentists, or podiatrists are often brought on-site to see patients.

Establishing senior care communities as appropriate post-acute care settings may become increasingly important as reimbursements shift toward a managed care model, and away from the current fee-for-service system based on volume rather than quality. The Centers for Medicare & Medicaid Services (CMS) began docking reimbursement rates on Oct. 1 for hospitals with readmissions above a certain threshold.

This has prompted hospitals and health systems to partner with a continuum of providers to ensure discharged patients receive the best quality of care in the most cost-effective settings. Favorable readmission metrics have placed the Lourdes-Noreen McKeen Residence in a great position to participate in these partnerships, says Brown.

LNMR has met with the administrative staff of a prominent local medical center to discuss referral arrangements for discharged hospital patients based on the exemplary readmission rates and outcomes demonstrated by the senior care community.

“A conversation is happening,” Brown says, adding that the foundation for a partnership is there. “The nurse practitioners are such a key component with [preventing] rehospitalizations or repeat illnesses within the building. It helps to stay on top of residents’ conditions and care management.” 

Written by Alyssa Gerace 

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