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

Email Address:

Telephone Number: (401) 528-3256


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PAC-2 - Preventing Hospital Re-Admissions

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