Debi Damas
Debi Damas

By reducing hospitalizations by 25%, an estimated $2.1 billion could be saved. Of Medicare beneficiaries residing in a long-term care facility, 27% had a skilled stay during the year, averaging 40 covered SNF days. When you consider that 68% of residents have some degree of impaired cognition, the potential for a bounce-back becomes even more of a reality. 

What can you as a post-acute provider do to help?

Training, communication and assessments are key ways that your organization can start to tackle this problem. 

A thorough assessment upon admission is key to knowing the person, their baseline, and potential issues that already exist; and ongoing assessments may be even more critical to reducing rehospitalizations.

During walking rounds, nurses and nursing assistants should not just be making sure that all the work was done, but sharing pertinent information about what they observed during their shift that may be indicative of a change in condition – less meals eaten, or increase in behaviors for instance.  This will let the oncoming shift know what they should be keeping an eye on. 

By using consistent assignments, staff members can become intimately aware of small changes that occur that may be indicative of a decline coming on. That alone is huge in management of an illness. If caught early, there is less chance that the person would need to be sent out. 

Why is this really important?

All organizations should be aware of their rehospitalization rate and should be addressing this in their QAPI meetings – why did they go out, what could have been done to prevent it, was there a systems problem, were subtle indicators noted and charted, does a nurse need education, etc? In other words, look for the root cause and solve that – what was missed in the regular assessments or was there an error in judgment.

Be sure that you look at medications.  This is important to prevent adverse reactions between medications, which is a significant cause of bounce-back.  Residents may return on new and various medications. Some may be new to the resident and may interact with current medications.

Enlarge your teams for early interventions. It is becoming more prevalent in senior care organizations to have nurse practitioners or physician assistants as part of their care team.  Having advanced practice physician extenders immediately available to intervene can also reduce bounce back.

Document, report and communicate. An area where there is probably the most opportunity is transitioning care areas. Provision of important information from the sending care area to the receiving care setting is critical. If there is not a comprehensive report provided, the receiving care area will not have the information they need to provide the appropriate care and that may result in a bounce-back. 

Preventing bounce-back is crucial to your relationships with hospitals. They want to partner with providers that will provide high levels of care and not send them back to the hospital when they could have handled.

To understand how to further prevent bounce-backs and your organization’s role in reducing rehospitalizations, download the white paper, ,A Puzzle of Prevention: Recognizing the Role of Delirium in Preventing Rehospitalization, or try Relias Learning’s free online course Delirium, Dementia, and Depression.

Debi Damas, RN, is the senior care product manager at Relias Learning.