Hospitals, nursing homes see readmissions drop with transitional care

With reimbursements on the line, hospitals are looking to improve their readmission rates. Hospitals, along with nursing facilities, across the country are using transitional care to keep patients from returning to the hospitals.

In fiscal year 2013, hospitals will be penalized by 1 percent for high readmission rates under the Hospital Readmissions Reduction Program. In 2014, they will face a 2 percent penalty and, in 2015, a 3 percent penalty.

"Hospitals haven't typically seen themselves responsible for what happens after (patients) leave," Alan Bier, chief medical officer at Gwinnett Medical Center, said in an Atlanta Journal-Constitution article last week. "That's really what is changing."

Gwinnett Medical and WellStar Health System, both in Atlanta, use transition coaches to help guide patients through discharge and follow up. A transition coach may go with the patient to a doctor visit and follow up with calls. In addition, patients receive their personal health records and can call coaches with questions after they leave the hospital.  

Similarly, nursing facilities are partnering in care coordination to keep patients from rehospitalization.

"We realized that the handoff from the hospital to the nursing home was a point of vulnerability where things could potentially fall through the cracks," Denise Remus, a nurse and chief quality officer for BayCare Health System in Florida, said in a St. Petersburg Times article today.

Although length of stay has decreased in recent years, patients are released to nursing homes earlier, according to the article.

Therefore, St. Anthony's Hospital, under BayCare Health System, worked with Pinellas Point Nursing and Rehabilitation to cut readmissions of heart failure patients. Nursing home staff monitored at-risk patients, running tests and screening for signs such as fever and confusion. Within six months, the partnership eliminated sepsis as a reason for readmission to St. Anthony's.

Similarly, long-term facility operator Signature HealthCARE this year launched a pilot program, TransitionalCARE, focusing on care between hospitals and nursing facilities, as well as from nursing facilities to the home. At Signature HealthCARE Saint Francis, in Memphis, Tenn., the transitional program has seen the number of patients readmitted to hospitals within 30 days fall from 28 percent to 13 percent since March, according to a column by Signature HealthCARE media relations manager Ben Adkins, published in McKnight's Long-term Care News & Assisted Living on Friday.

Three transitional coaches provide six coaching sessions during the patient's stay, helping them understand their diagnosis and medications to help manage their own health.

"This program has allowed us to partner with hospitals for a shared commitment to improve the continuum of care, which has shown to reduce hospital readmissions," said Kara Plaks, Business Development Leader for Signature's Post Acute division.

Hospital readmission rates cost Memphis $71 million in 2009, according to a new report from Qsource, a Tennessee quality improvement organization.

The Centers for Medicare & Medicaid Services estimates the overall costs of avoidable readmissions are more than $17 billion a year, reported The Commercial Appeal last week.

For more information:
- read the St. Petersburg Times article
- here's The Atlanta Journal-Constitution article
- read The Commercial Appeal article
- check out the McKnight column

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