Reducing hospital readmissions is a challenge for the entire healthcare continuum. It is all too common and it is costly and in many cases avoidable. Skilled nursing facilities and subacute facilities are not currently being hit with financial penalties for hospital readmissions. The Centers for Medicare and Medicaid Services (CMS) will change this policy in October of this year. Currently hospitals bear the brunt of these financial penalties for readmissions, as they are the facilities partner it is in everyone’s best interest to reduce the readmissions whenever and wherever possible.
This is an opportunity for hospitals and skilled facilities to develop a new and better model, which should be a win, win, win for the hospital, the facility and the patients.
It is imperative that SNF’s maintain a very strong and positive relationship with their hospitals. The positive acceptance of subacute care by the hospitals has permitted the discharge of sicker patients. These patients are discharged from the hospital for rehabilitation or some acute therapy care. When these patients are moved off of the subacute unit to the typical skilled unit they might not understand their physical limitations and it is up to the skilled unit to provide the guidance and the care necessary for their maintenance. The first 24-48 hours post discharge from the hospital setting are the most crucial no matter if it is to the SNF or the subacute unit.
In many cases the discharge chart does not provide the complete picture of the patient and it up to the facility, be it subacute or SNF to fill in the gaps. This can be done by additional communication with the unit manager in the hospital, discussions with the family or speaking directly to the patient.
Facilities have strongly focused on the educational component to help better understand and act on patient discharge information. Communication is essential between shifts if patients are to be maintained in the facility.
Readmissions is going to continue to be a critical issue for patient care as well as for the financial viability of the facilities. Delivering quality care is the goal and reducing readmissions is just one component.