Readmission prevention: The role of post-acute providers

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Dr. Eleanor Barbera
Dr. Eleanor Barbera

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.  

Presenters emphasized that many readmissions can be averted through the practice of contacting residents and their families after discharge. The problems that occur in this care transition frequently can be alleviated with information and practical assistance, such as clarification about medications or assistance with obtaining medical equipment or with arranging transportation to appointments.

For those considering outsourcing this role, Nexus Health Resources, one of the vendors at the conference and contributor to the Gold Medal win in McKnight's Tech Awards in the Transitions category, offers a call center and transitional care software that can help “track and manage every patient and caregiver interaction.”

Post-acute providers should communicate monthly with referring hospitals, sharing readmission prevention data and solidifying the referral relationship.

Readmitting residents to skilled nursing facilities within 90 days doesn't count as a hospital readmission. Conference organizer Josh Luke, Ph.D., FACHE, founder of the National Readmission Prevention Collaborative, therefore suggested that SNFs increase their ability to handle medical-surgical level patients. He also recommended diversifying into home care, private duty care and assisted living, or aligning with a hospital that offers these services.                             

Resident perspective

Rehab residents frequently make comments to me about the many medical professionals (myself included) making money off of them during their illness. In the fee-for-service model, their cynicism is all-too-frequently well placed.

With value-based care, I hope not to hear cynical remarks about extreme and inappropriate efforts providers are making to avoid hospitals. Instead, with proper care coordination and support in the community, rehab residents and their families will be expressing relief and appreciation that unnecessary hospitalizations and readmissions were averted.

Eleanor Feldman Barbera, PhD, author of The Savvy Resident's Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is the Gold Medalist in the Blog-How To/Tips/Service category of the American Society of Business Publication Editors Midwest Regional competition. A speaker and consultant with over 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at MyBetterNursingHome.com.

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