Readmission prevention: The role of post-acute providers

Posted by Dr. El - October 25, 2017 - McKnight's LTC News, Transitions in care - No Comments

The current focus in healthcare is to avoid unnecessary hospitalizations. This is good news for seniors, who tend to fare poorly in the hospital environment, as described here. The article below details efforts being made to create smoother transitions between hospitals, rehabs, home and any other care providers along the way. As always, family members are the best care transition partners because they know the elder’s history and behavior and have seen the elder through all the transitions.

Here’s my latest article on McKnight’s Long-Term Care News:

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Readmission prevention: The role of post-acute providers

Long-term care providers have an opportunity to thrive with value-based care, escape cynicism and join the growing wave successful at avoiding readmissions.

Last week, I was part of a panel discussing readmission prevention at the National Readmission Prevention Collaborative’s C-Suite Invitational: New York Transformational Healthcare, which focused on Accountable Care Organizations, bundles and readmissions. The goal of the forum was identifying ways for providers at all ends of the healthcare continuum to prevent hospital readmissions and to thrive in a value-based care model.

Unlike fee-for-service care, which compensates providers for each procedure, value-based care pays for the episode of care, making it essential to coordinate between providers and to avoid unnecessary medical utilization. Efforts to avert hospitalization and readmission are paramount.

The conference offered several takeaways for skilled nursing facilities and other post-acute providers.

From hospital to post-acute provider

Presenters emphasized the importance of being part of a continuing care network rather than a stand-alone facility and of working closely with referral sources. Because crucial information is easily lost during care transitions, best practices suggest a “warm handoff” rather than an exchange of information on paper or via computer, meaning that providers have an actual conversation about care.

To facilitate this, both the referral source, such as the hospital, and the accepting organization, such as the nursing home, should have someone to collect and relay information. To reduce costs, this needn’t be a clinical role as long as the necessary details are conveyed. Communication can be streamlined using a “hotline” between the hospital and the post-acute provider so that phone calls can be made directly rather than routing through the emergency department.

The transition to home

Hospitals are being monitored for readmissions and may have several post-acute care options. The facility most likely to prevent rehospitalization after discharging residents is the one most likely to get referrals.

For the entire article, visit:

Readmission prevention: The role of post-acute providers