Ending Hospital Readmissions: A Blueprint for SNFs

Avoid the pitfalls that cost SNFs billions each year in preventable rehospitalizations

An informed and proactive nursing home staff is a vital weapon in the struggle to keep residents from being readmitted to the hospital. Ending Hospital Readmissions: A Blueprint for SNFs delivers several practical strategies your facility can employ to combat this problem, such as enhanced resident assessment and documentation policies, provider partnerships that improve transitions of care, staff education tools, and methods to achieve resident and staff involvement. This book will show you the true financial consequences of unchecked resident readmission and provide you with the tools to do something about it!

The information in this book will help you develop a plan to:

• Ensure smooth care transitions through resident education and effective communication with staff and other care providers
• Reduce costs associated with rehospitalizations
• Prevent the incidence of hospital readmissions resulting from avoidable complications, medication problems, and adverse events
• Encourage the resident and family to participate in the transition to ensure satisfaction with quality of care
• Maintain or improve the resident's quality of life

Table of Contents

• Chapter 1: Introduction—Why Are Hospital Readmissions a Problem?
  • Medicare and Senior Healthcare
  • Rehospitalization
  • Implications of Rehospitalizations
  • Rehospitalization and Revenue
  • The Patient Protection and Affordable Care Act
  • Transitional Care
  • The Bottom Line
  • Why Should I Care?
  • Where to Begin
• Chapter 2: Identifying the Origins and Causes of Problematic Transitions
  • Interfacility Communication
  • Long-Term Care Facility Concerns
  • Physician Concerns
  • Schedule Drug Issues
  • Emergency Department Concerns
  • Patient and Caregiver Concerns
  • Surprising Information
• Chapter 3: Reasons for Inappropriate Hospitalization and Rehospitalization
  • Most Common Causes of Inappropriate Rehospitalization
  • Financial Incentives
  • Early Discharge
  • The Weekend Exodus
  • Medical Diagnoses and Conditions That May Predispose Residents to Acute Changes in Condition
  • New Onset Problems Suggesting an Impending Change in Condition
• Chapter 4: Risk Factors
  • Identifying Risk Factors
  • The Polypharmacy Problem
  • Medication Reconciliation
  • The Patient Self-Determination Act
  • Hospice Care
• Chapter 5: Medicare Part A Basics
  • The Medicare Program
  • Observational Hospital Admissions
  • Medicare Paperwork in the Hospital
  • Inpatient Medicare Coverage and the SNF
  • Medicare Level of Care and the Long-Term Care Facility
  • Important Reimbursement Issues
  • Trend Setting
  • Documentation
• Chapter 6: Strategies to Avoid Rehospitalization for Caregivers
  • Avoidable Readmissions to the Hospital
  • Strategies for Reducing Avoidable Readmissions
  • Standard of Care for Monitoring Residents With Acute Illness or Infection
  • Initial Assessment and Documentation Guidelines for Conditions for Which Monitoring Is Required
  • Specific Responsibilities
  • 24-Hour Change of Condition
  • Change of Condition Communication
• Chapter 7: Strategies to Avoid Rehospitalization for Managers
  • Managerial Information for Reducing Acute Care
  • Transfers
  • Facility Admissions and Readmissions
  • Commitment
  • Establishing or Modifying a Facilitywide Program
  • Philosophy of Care
  • Director of Nursing
  • Managing Potential Barriers to Success
• Chapter 8: Ensuring a Smooth Transition
  • Transition Initiatives
  • Resident-Centered Transitions
  • Readiness for Discharge
  • Risk for SNF Readmission or Rehospitalization
  • Pre-Transition Issues
  • Risks Associated With Poorly Executed Transitions
  • Preparing Paperwork
  • Advance Directives
  • Medications
  • Preparatory Activities
  • Coordination With Others
  • Home Discharges
  • Steps to Take Immediately Before Discharge
  • Post-Discharge Activities

Audience

DON, CNO, MDS coordinator, director of rehab, therapy director, administrator.

About the Author

Barbara Acello, MS, RN, is an independent nurse consultant and educator. She has worked in long-term care for more than 33 years. In addition to owning and operating a school for nursing assistants, she helped write and develop mandatory state curricula for nurse aides and EMTs.

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