Curb readmissions with hospital, long-term care teamwork

Tools

To reduce readmissions, hospitals should work with long-term care (LTC) facilities, as care gaps from inferior communication at discharge and poor follow-up often send LTC patients back to the hospital, according to an article in Hospitals & Health Networks Daily.

With the Centers for Medicare & Medicaid Services cutting payments for excess readmissions for congestive heart failure, heart attacks and pneumonia starting in October, reimbursements raise the financial stakes for hospitals to help improve the quality of care provided at LTC facilities and keep patients from returning to hospitals unnecessarily.

Hospitals can integrate staff at LTC facilities, providing the resources and expertise needed to bring patient care up to par, the article noted. For example, they can assign a physician leader or nurse manager to manage post-acute care.

Also, hospitals can help streamline clinical processes at LTC facilities to reduce care delays. Putting a discharging physician in control of medication management, according to H&HN Daily, will ensure the right prescriptions are available when the patient arrives at an LTC facility.

And because few LTC facilities have electronic medical record (EMR) systems, health IT enhancements and temporary workarounds will help improve communication and care coordination between hospitals and long-term care providers, according to the article.

Hospitals, for example, can print out the continuity of care document from the inpatient EMR and have the patient bring it with them to the LTC facility, while LTCs can download hospital discharge information from online portals through health information exchanges without needing an EMR, MetroChicago Health Information Exchange Director Terri Jacobsen told H&HN Daily.

For more:
- read the H&HN Daily article

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