Post Acute Care

2018 AHCA/NCAL Annual Convention

PAC-2 - Preventing Hospital Re-Admissions

Monday, October 8
3:15 PM - 4:45 PM
CE: NAB: 0 | Nurses 0

Patients admitted to an SNF from a hospital have a high rate of early, unplanned readmissions that add to the already growing costs of Medicare. A majority of the literature on care transition interventions to reduce preventable hospitalizations is focused on discharges from the hospital to a nursing facility or back into the community; few studies detail how evidence-based interventions apply to patients being discharged from the nursing facility back into the community. Healthcentric Advisors designed an evidence-based, community-centered nursing facility project to address unnecessary or potentially avoidable hospitalizations using a systematic process for discharging residents back into the community. The project, implemented among a cohort of facilities in Massachusetts, uses key elements from the hospital-based Project Red and Coleman’s Care Transitions Intervention. It is centered on an evidence-based after-care plan (ACP) that educates patients and their families regarding post-discharge care management. Data collection and a Medicare claims-based analysis took place from March 2017 through March 2018. Preliminary results from among 1,793 nursing facility admissions are promising: Participants have demonstrated the feasibility of implementing the core elements of Project Red (93 percent of patients received ACP at discharge), and claims provide evidence for a downward trend in readmissions among the participating facilities (readmissions 30 days post-hospital stay decreased by 2.44 percent in the first three months). Complete results will be available for the conference. This session will describe the intervention; recent results from this project, including the impact on readmissions; utilization of ACPs to promote patient satisfaction and understanding of their care; and best practices for dissemination to other communities. This topic is timely and significant as Nursing Home Value-Based Purchasing payments begin in 2019, increasing the urgency for nursing homes to identify successful strategies to improve care coordination.

Learning Objectives:

Gail Patry, RN, CPEHR

Chief Program Officer
Healthcentric Advisors

Gail Patry RN, has more than 30 years of experience in healthcare and quality improvement and as Chief Program Officer at Healthcentric Advisors, she is responsible for the management & oversight of the Medicare QIO contract in all healthcare settings in RI, MA and ME as well as oversight of a major subcontractor managing CT, NH, and VT. In addition to overseeing the implementation of the QIO contract, she oversees business development for the QIO and has fiduciary oversight responsibility.
Ms. Patry’s experience includes leading both local and national projects including the Medicare-funded Nursing Home Quality Improvement Support Center (QIOSC) from 2002-2008, assisting Medicare Quality Improvement Organizations (QIOs) across the country in implementing the Nursing Home Quality Initiative.
Prior to joining Healthcentric Advisors, Ms. Patry was the nurse manager of a 40-bed sub-acute unit in a 120-bed nursing and rehabilitation center. This experience gives her expertise with real-world quality improvement and measurement issues, as well as a thorough understanding of what patients and families expect and need.
In addition to her nursing degree earned at the University of Nebraska, Ms. Patry has a BS in Health and Social Science from Roger Williams University and is nearing completion of a Masters in Nonprofit Leadership at LSU.


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PAC-2 - Preventing Hospital Re-Admissions

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