The app aims to improve the exchange of patient information and better inform the care provided to nursing home patients. It bridges the gap between medical records systems that use different data storage technologies and offers patient information in a format influenced by nursing home workers themselves.

The development stems from a study that started with a team of experienced nursing home nurses identifying key data points and helping shape the way the tool works and its visual format. The process was detailed in the Journal of the American Medical Directors Association.

“The reason that people go to a nursing home after being hospitalized is due to their needs for additional support for medical complexity. Receiving information that is inaccurate or delayed ties the hands of the clinical providers in the nursing home, making it more difficult to provide safe and appropriate care at the time of transition,” co-developer and study author Kathleen Unroe told McKnight’s Long-Term Care News Friday. “Medications for pain or other medical conditions could be delayed due to a lack of up-to-date information.”

Some conditions, especially behavioral health needs, may also be missed by receiving facilities, and those facilities may be unequipped to treat such needs.

 “Not only can this place the patient’s health at risk, it can also put the health and safety of other residents (in the patient’s home or in a SNF), as well as provider staff, at risk,” CMS Director David Wright wrote in a memo to hospitals earlier this year. “These situations can cause avoidable readmissions, complications, and other adverse events.”

Robust info sharing helps staff

Preventing unnecessary readmissions is one of Unroe’s main areas of focus as a research scientist for the Regenstrief Institute at Indiana University.  She’s been bewildered by the lack of consistency or movement toward interoperability between healthcare settings.

“This is an issue we have had the technology to solve for a long time and I and other clinicians are frustrated that the situation varies so much by facility and by discharging hospital,” she said. “I appreciate that CMS is pushing hospitals to take responsibility for transmitting appropriate and timely information to nursing homes to support care transfers.”

The app development project focused on how critical information should be optimally presented and integrated into nursing home workflows. 

“A nursing home admission nurse or admitting physician should not have to sift through a pile of paper or dig through lengthy electronic health records to capture basic pieces of data that we need to know on each admission,” Unroe said.

The app provides “robust” information quickly to support what the research team called a seamless transition of care across settings, regardless of which electronic medical record systems the two facilities use. It addresses residents’ medical needs as well as what supports they might need for activities of daily living, explained co-author Joshua R Vest, PhD, of the Department of Health Policy and Management at Indiana University. 

And the benefits won’t necessarily be limited to patients, Unroe added.

“Costs of staff training are reduced if the time is put into thoughtful, user-centered design, such as the results presented in this study,” she said. “Increasing sophistication of medical record systems and a greater push for interoperability mean it is possible to get widespread solutions in nursing homes into use.”

Unroe now plans to advance the prototype into a fully scaled tool for broad use on computers and handheld devices. The researchers plan to test it in real time with actual transfers to confirm that it will support nursing home nurses “to efficiently and safely admit patients as well as to ensure that there is no disruption in the clinical care plan created by the hospital due to transition to a nursing home,” Regenstrief said in a press release.

Rehospitalization is not always avoidable for this fragile group; however, SNF leaders continue to seek out and implement successful strategies to reduce the stress associated with transfers between care facilities and improve residents’ quality of life. 

One such strategy is nutritional interventions, which have emerged as a crucial approach in preventing hospital readmissions and promoting overall health and well-being among this vulnerable population.

Common causes of hospital readmissions 

There are many reasons a resident may need to be readmitted after a recent discharge from the hospital. Two of the most common factors that increase the risk, however, include: 

1. Multiple comorbid conditions such as heart failure, chronic obstructive pulmonary disease, and diabetes. According to the National Council on Aging, nearly seven out of 10 older adults have two or more chronic conditions. Not surprisingly, the more chronic conditions a person has, the more likely he or she is to be readmitted to a hospital within 30 days.
2. Poor nutritional status, especially among residents who were malnourished prior to their first hospital stay, is another important readmission risk factor. It’s estimated that as many as half of long-term care residents have (or are at risk of having) malnutrition, which can result in delayed recovery and higher vulnerability to infection. In addition, one-third of residents who were well-nourished before a hospital stay may develop hospital-acquired malnutrition. Malnourished residents are 23% more likely to be readmitted after hospital discharge.

Nutritional interventions in skilled nursing facilities 

In SNFs, implementing targeted nutritional interventions can have a profound impact on residents’ health outcomes. Person-centered menu planning, nutritional supplementation, fortified meals and nutrition counseling can lead to a significant reduction in hospital readmissions.

These interventions not only improve nutrient intake but also help manage chronic conditions and promote faster recovery. Moreover, individualized nutrition plans tailored to each patient’s needs and preferences are essential for ensuring compliance and better outcomes. 

It’s imperative in the skilled nursing setting for registered dietitians to be actively engaged not only in the community’s nutrition plan overall, but also in individual residents’ ongoing evaluation and care plans. A dietetic professional who implements a proactive model of medical nutrition therapy on an individualized basis and is attuned to residents at higher risk of readmission can make the difference between life and death.

Malnutrition

The person-centered approach that registered dietitians employ helps address the multifaceted factors contributing to malnutrition, ultimately reducing the risk of hospital readmissions. As part of this approach, SNFs should implement a comprehensive malnutrition platform (CMP). The CMP is a succinct process, following consistent protocols with recognized guidelines for identifying, treating and documenting malnutrition. When implemented fully, communities not only reduce the risk of hospital readmissions due to malnutrition, but they also significantly boost the probability of appropriate reimbursement (see sidebar). 

There are a variety of nutritional strategies that can be implemented to address malnutrition and — most importantly — understanding the root cause(s) of nutrient deficiency. These include (but are not limited to): 

• Offering delicious food that meets the cultural/religious preferences of the resident 
• Providing nutrition supplements to quickly increase calorie and protein intake 
• Modifying diet texture; consulting with a speech-language pathologist (SLP) 
• Fortifying foods and beverages 
• Scheduling individualized dietary counseling 
• Serving meals with adaptive feeding devices such as high-sided dishes, non-skid plates, etc. 
• Ensuring oral care is adequate 
• Referring residents to psychiatrists, dentists, and other relevant professionals

An interdisciplinary approach 

To help prevent the occurrence of hospital readmissions, there is a growing emphasis on care coordination among interdisciplinary team members to address nutrition issues.

Registered dietitians are critical as principal members of the SNF interdisciplinary care team because they are the only ones on the team: 

1. Educated in nutrition therapy, the therapy of diets and how that plays into residents’ chronic disease states and recovery; 

2. Using the most recent advances in nutrition science to reduce residents’ risk of readmissions and mortality; and 

3. Experienced in collaborating with interdisciplinary care and food operations teams to provide an exceptional resident experience.

Strengthening the partnership between dietitians, clinicians, culinary staff, SLPs, occupational therapists or any other healthcare professional involved in the case can contribute to reducing readmissions and improving health outcomes for vulnerable patients. 

Phyllis Famularo, DCN, RD, FAND, LDN, serves as a Senior Manager of Nutrition Services for Sodexo Seniors and has worked with the older adult population nutrition in the Northeast for over 30 years. Her primary duties include training of dietitians and regulatory compliance. She is an RDN with a doctorate in clinical nutrition from Rutgers University.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

The team looked specifically at readmission rates for people with congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) after they were discharged to skilled nursing facilities. Authors compared the rates of people readmitted to the hospital 30 days after being discharged. They studied people the year before care protocols were introduced and two years after the protocols were enacted. There were separate protocols for COPD and CHF.

The protocols consisted of medical provider or nurse assessments on admission to nursing facilities. The protocols also included multidisciplinary care planning, as well as medication management strategies. 

Researchers examined 1,128 people who were in hospitals the year before the protocols were put into action. They also evaluated data on 2,297 people in hospitals and discharged to nursing facilities after the protocols began taking effect. About half of them had CHF without COPD and had the standardized protocol; 47% with COPD who didn’t have CHF also had the standardized protocol in effect. Of those with COPD and congestive heart failure, 49% had protocols in play.

Of people with the COPD protocol, readmission fell from 23.5% in 2011 to 12.1% in 2015. There were fluctuations for people on the CHF protocol. Overall, when people were exposed to standardized care protocols in the nursing facilities, there were improvements in readmission rates, the authors said.

“Our findings demonstrate great value in standardizing care management and strengthening collaboration with chronic care settings to facilitate a smooth transition of medically complex patients discharged from large health care systems,” they wrote in the report. “Future interventions could consider assessing nonclinical factors that may impact preventable hospital readmissions.”

The authors say that partnerships between hospitals and skilled nursing facilities can ease transitions in care and prevent unneeded readmissions. A key factor is having a nursing educator train nursing facility staff on the protocol and working with them to monitor people and track how well they stick to protocol, the authors noted.

But, with time, as I have worked with thousands of patients, hundreds of teams, dozens of initiatives and at least five large healthcare organizations, I have a better understanding and agreement towards the need to focus on hospital transfers.

My most recent understanding of the need to focus on this outcome, comes from a very recent case. One of my collaborating nurse practitioners had called me about this 62-year-old resident of a nursing facility who had been lethargic and had fluctuating blood pressure and blood sugar values. With a history of coronary artery disease, hard to control diabetes that required daily insulin, along with hypertension and history of wounds and other infections, he had been manifesting confusion (delirium). 

The practitioner, who had been in this facility now for five months, had initiated and participated in a weekly hospital transfer review process, almost creating a campaign to convince nurses that more can be done for patients in nursing homes, rather than just send them out when they get sick. 

In these weekly meetings (I get to join most of them), the team reviews all transfers for the week and then discusses any possible clinical flags (e.g., fever or cough that was not assessed etc.) that were missed for these cases in the preceding seven days. The team that includes the director of nursing, charge nurses and other team members, in a blame-free environment (that takes time to establish), labels each transfer as “avoidable” versus “unavoidable.” The director of nursing creates a list of best practices that is then used to teach others in the facility. Before adjourning, the team prepares to receive the patients back and does a deep-dive into polypharmacy, with plans to modify medications to minimize risks, on patient’s return.

It was obvious that the efforts of the practitioner had borne fruit because, in this case, despite a very engaged family who felt that the patient should be transferred to hospital, the nurses were happy to work with the practitioner to prevent his transfer. The practitioner had come up with a reasonable differential diagnosis (e.g., hyperglycemia and metabolic causes for his delirium, possible occult infection, drug-drug interactions, etc.) had ordered stat labs, a chest X-ray, and had started the patient on intravenous fluids. 

By the time the practitioner called me, the blood pressure and other vital signs were stable. We again went over the possibilities and given the improved vitals, agreed to stick with the plan and to monitor closely. By next day, the resident appeared to be himself again, as the delirium seemed to be resolving and his blood sugars too had steadied. A hospital transfer had been averted, sparing the resident from many hassles, and saving thousands of healthcare dollars!

Preventing a transfer, as is evident in this case, is not a function of a practitioner just being courageous and confident. I will actually argue that bold decisions, in the absence of a team that is well-aligned with the concepts and has the competence and confidence, may be risky. In this case, months of team-based learning that garnered team’s confidence in each other, had shifted the culture, and set the stage for collective and appropriate valiance.

When I reflected with the practitioner, she stated, “Arif, the fact that none of my nurses demanded that I send this patient out — which was not the case a few months ago — gave me the confidence that we as a team could do this.”

This reflection has helped me validate that preventing avoidable transfers needs a culture where team members trust and support each other, and that simplistic solutions, e.g., assigning after-hours calls to third-party partners with telehealth capabilities, are just not going to cut it.

Arif Nazir, MD, Chief Medical Officer for Abode Care Partners, is a leader in geriatric and frailty care. Besides practicing on the frontlines, Nazir oversees quality improvement and delivery of medical services across several large post-acute care organizations providing services across many states.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

Many nursing homes are moving too quickly to implement evolving technologies before their worth is fully known, cautions Nazir, who was recently appointed consultant chief medical officer at American Senior Communities.

“If you bring premature technology like remote patient monitoring, they actually add a significant burden for the staff,” Nazir, MD, told McKnight’s Long-Term Care News Thursday. “I’m not saying we shouldn’t invest in it. It’s just not where it needs to be yet. … Right now, the data points create a lot of noise and they can create a lot of extra work.”

For nursing homes already doing all the right things, smart technologies can be icing on the cake. But in most facilities, there needs to be more focus on first baking the cake itself, he says.

That attention to basic ingredients, in this case those needed for creating high-quality patient care, is the focus of Nazir’s work with ASC, as well as Signature Health, where he has been chief medical officer since 2016.

Just over a year ago, Nazir joined BrightSpring Health as chief medical officer of its primary care programs. As a consultant to two major providers, and possibly more in the future, his role is to bolster the recruitment and strategic use of engaged medical directors and other advanced practice clinicians.

For this former president of AMDA – The Society of Post acute and Long-Term Care Medicine, this is the likely solution to many of this sector’s challenges and a way to seize on the medical complexity and demographic opportunities coming in years ahead.

Coordinating key clinicians for quality

That’s one reason he was eager to join the team at ASC, which is Indiana’s largest nursing home operator. 

“We find American Senior Communities is one of those progressive organizations that actually is aiming to do the right things,” Nazir says. “Most importantly, they actually fully understand the importance of how quality is going to play a role in the value-based structures of the future, actually of the past, present and the future.”

They’ve already adopted certain tenets that demonstrate they see the  importance of medical directors and physicians working  in partnership with nurse practitioners and prescribers, Nazir says. But coordination among those parties has always been a challenge for providers, especially in buildings where few clinicians are routinely on site.

“Our biggest problem is that we just have not invested in and taken the time to ask how the teams really should be working together,” he adds. “That is what American Senior was looking for: innovation in teamwork and partnership to improve quality of care.”

Nazir’s work with the ASC leadership team, which is shifting as CEO Donna Kelsey moves toward retirement, is beginning with refining hiring efforts and building a structure that each facility’s team can follow. Much of that will include setting clear expectations of the medical director, and giving him or her clear guidance on when to intervene in facility-wide programs or insist on and lead change.

While he’s frequently visiting partner facilities under the BrightSpring initiative, Nazir’s goal is to build strong systems that on-the-ground teams can adhere to and perfect over time.

He’s a champion for such standards, which he believes would be helpful nationally. He referenced a recent JAMA Network Open study that found the share of nursing homes working with advanced care practitioners, specifically SNFists, had soared from 13.5% of facilities in 2013 to 52.9% in 2018. Despite that fast growth, the presence of those professionals hadn’t reduced hospital readmission rates, a statistic often used to measure quality.

It’s incumbent on nursing home leaders to make sure those clinicians are being empowered and authorized to do more than just their required rounding — but also to be clear on what their physicians can help them achieve. 

“We have given them a whole lot to do, which creates vagueness in their role,” Nazir says. “We need to know: What do physician leaders in American [nursing homes] do? What kind of structure do they need to work in? How can they partner better day in day out with the staff and improve their workflow, rather than, sometimes, inadvertently becoming a barrier to workflows? I think to me, that is going to be the most exciting thing for me to work on,” Nazir says.

The big 3 subject areas

A mandate for Nazir’s teams will be developing core elements for medical directors to lead the way on; those could include improvement initiatives or compliance areas such as rehospitalizations, polypharmacy management or infection control.

“If our advanced clinicians and our medical directors would just give us great focus on these three elements and be a great partner to us on these things, we would be light-years ahead of where we are in quality,” he said.

Of course, rolling out any significant change in how clinicians operate in nursing homes will depend on who fills such roles. Nazir’s first step with new partners is helping them find “A” players, those with the attitude and skill set needed for long-term care’s special populations. He says he looks first for candidates with caring, compassion and humility.

“We can teach and learn everything else, but if you’re not going to be compassionate about the work you do, if  these patients are just numbers for you, they’re just revenue, this building is just a chore for you … that’s the kind of person who will never be a successful physician leader or will never be able to drive outcomes.”

In addition to publishing proposed pay rates and extensive changes to its value-based purchasing program in the fiscal 2024 SNF Prospective Payment System draft, the agency also laid out extensive changes to its quality reporting program.

Under the QRP, facilities are required to track and report specific data through MDS and other systems. Those that don’t submit enough comprehensive data are docked 2% of their annual Medicare pay.

In the rule issued last Tuesday, CMS proposed the adoption of three new measures, the removal of three measures and the modification of another. In addition to changing the measures themselves, CMS is proposing to increase the amount of information required to keep full payments. Starting in fiscal 2026, providers will have to submit 100% of required quality measures for 90% of patients, up from the current 80% of patients.

Adding more reporting requirements presents another challenge to many providers, most of whom are struggling to fill frontline care positions — as well as assessment professionals  who are often responsible for submitting quality metrics.

“We have to keep in mind that more measures don’t necessarily mean better care,” said Melanie Tribe-Scott, BSN, director of quality innovations at Zimmet Healthcare Services Group. “It’s really the quality of the measure we’ve got to look at, and things change over the years so the measures should change too.”

All quality measures are published online on Care Compare, but only two QRP measures  (pressure ulcer rates and successful return to home or community) are currently factored into Five-Star quality measure score. Tribe-Scott anticipates that won’t change quickly with any of the proposed new measures, the earliest of which would launch in fiscal 2025.

The first proposed addition is a new Discharge Function Score measure, which would capture the share of SNF residents who meet or exceed an expected discharge function score. It will use mobility and self-care items already on the MDS. This measure has also been proposed as an addition to the CMS nursing home value-based purchasing program.

In effect, the measure replaces two other related measures that CMS is proposing to retire. But, noted Tribe-Scott, that still leaves providers with three discharge function measures to track and report.

And it’s a dual-purpose measure that providers could find challenging to shine in, observed Melissa Brown, chief operating officer at Gravity Healthcare Consulting.

“The Discharge Functional QRP Measure is based on whether the resident met or exceeded the expected functional outcomes, based on their specific clinical indicators including admission function score, age, and clinical conditions. This measure was selected, as opposed to whether the resident met the discharge goal selected on the MDS, because this would reduce the ability to ‘game’ the system, as CMS states in the Proposed Rule,” she told McKnight’s Long-Term Care News Friday.

Satisfied customers?

Tribe-Scott and Jodi Eyigor, LeadingAge’s director of nursing home policy, both view a proposal to add a Core Q: Short-stay customer satisfaction measure as a move that could benefit providers.

“It’s a positive that we have a customer satisfaction measure that would be included. That’s something that we have heard from our members for many years that they wanted,” Eyigor said last week. 

Added Tribe-Scott: “This is one that I feel is really going to benefit the provider. This is something we should probably already be doing on some level.”

The measure will assess how many discharged residents are satisfied with their stay over six months, using a standardized, four-question survey.

“It’s going to help the facility gauge their customer satisfaction. As we all know, that’s a huge part of marketing to our consumers,” Tribe-Scott said. “What I also see is this could really potentially decrease our 30-day readmissions because the resident will be more apt to be in contact with the facility to tell them if they’re having issues.”

But Eyigor offered one caution about the proposal.

“CMS says to have this CORE Q, you have to contract with an independent, CMS-approved vendor,” she said. “Independent vendor: That’s a great idea because we want to be sure this is valid data. However, this is going to cost you some money.”

Vaccination measures

CMS also has proposed the adoption of a COVID-19 vaccine measure for “up-to-date” patients beginning in fiscal 2026; it would be collected through a new MDS element but providers conceivably also would still report vaccines through the NHSN portal to comply with other requirements. The agency also proposed modifying the current COVID Vaccination Coverage Among Healthcare Personnel measure beginning in fiscal 2025 to capture up-to-date shots, rather than just the mandated primary vaccine series.

“We’re not going to see this go away,” Tribe Scott. “We kind of know that; it’s been three years now. … We’re going to continue to have to report on these.”

She added it would be important to follow Centers for Disease Control and Prevention definitions of “up-to-date.” The measure could change as vaccine requirements and availability do, especially if COVID shots eventually move to a seasonal schedule similar to that for flu shots.

Want to learn more about possible upcoming quality reporting changes? Check out the McKnight’s Daily Update newsletter or mcknights.com on Wednesday for a podcast in which expert Melanie Tribe-Scott shares additional insights.

Neil Kamdar, from the University of Michigan Medical School in Ann Arbor, and colleagues examined 30-day readmission rates and episode costs, including readmission costs for patients with versus those without ADRD in a retrospective study using 2012 to 2017 data. Overall, 66,676 admission episodes of care were identified for patients with ADRD along with 656,235 admission episodes of care for patients without ADRD. After propensity score matching, each group included 58,629 hospitalization episodes.

The researchers found that the readmission rates were 21% and 15% for patients with and without ADRD, respectively. Patients with ADRD had a higher cost of 30-day readmission ($8,378 versus $7,912, respectively). Total 30-day episode costs were $2,794 higher for patients with versus without ADRD across all 28 service lines examined ($22,371 versus $19,578).

“Patients with ADRD had higher readmission rates and overall episode costs than patients without ADRD. Avoidable hospitalization undermines the quality of life and longevity, possibly increasing the risk for adverse events for patients with ADRD,” the authors wrote.

Abstract/Full Text

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A planned audit by the Health and Human Services Office of the Inspector General is yet another expansion of its oversight of unnecessary hospitalizations of Medicare-eligible skilled nursing residents. Now is the time for facilities to get their audit readiness plans in order, a healthcare and reimbursement attorney said Wednesday.

“This is a reminder for SNFs to keep an eye on readmissions at their facilities and to understand the rate of readmissions and related reasons for the readmissions,” Alice Harris of Nexsen Pruet told McKnight’s Long-Term Care News.

“The audit activity related to this area is likely to increase, and it could be problematic for SNFs if the SNFs are not ensuring they have safeguards to prevent rehospitalizations to the extent possible.”

In the past, OIG has reviewed transfers to hospitals of patients with urinary tract infections, and concluded in 2019 that SNFs weren’t providing UTI prevention and detection according to care plans.

Citing studies that show that 78% of transfers of long-term care residents to hospitals were for one of five conditions — pneumonia, congestive heart failure, UTIs, dehydration, and chronic obstructive pulmonary disease/asthma — OIG will review hospitalizations of SNF residents with any of those conditions to discover whether their facilities could have done more to prevent the condition and subsequent transfer. 

The OIG also found that sepsis is preventable if the underlying cause is preventable and will include it in this audit.

The nation’s worst performing nursing homes when it comes to hospital readmission are already docked financially, and skilled nursing facilities aren’t the only providers targeted for too often allowing patients to need more acute care. Hospitals have faced such scrutiny and penalties for more than a decade. Last year, the Centers for Medicare & Medicaid Services reduced payments to nearly half of hospitals.

Since 2018, SNFs entire Value-Based Purchasing program has been built around readmission performance. Earlier this year though, a JAMA study by researchers at UPenn and Stanford found that just 52 skilled nursing facilities of nearly 15,000 were able to improve enough from a poor baseline score to avoid a financial penalty, despite large reductions in readmission rates.

Taken all together, the financial incentives, penalties and increased audit activity reflect a concerted federal policy initiative to reduce rehospitalizations.

“While adding audit activity on top of quality metrics and potential penalties feels duplicative, the audit activity is predictable when an area of concern is continuing to be a problem area,” she said.

The February JAMA study noted above found that nearly one-quarter of those admitted to SNFs are readmitted to a hospital within 30 days, and those readmissions are associated with a quadrupled mortality rate within 6 months.

In a blog Tuesday, Harris said  facilities should prepare for even more oversight by:

1. Examining policies, procedures and practices related to the identification of the six conditions identified by the OIG, including the content of care plans and implementation of care plans;
2. Educating and training all staff on the detection, prevention, treatment and care planning related to the six conditions;
3. Conducting a data analysis of trends related to the frequency and cause of inpatient hospitalizations, and craft a response plan to examine patterns; and
4. Using information from a data analysis or a random sample to self-audit.

In a new study, researchers followed nearly 1,100 patients discharged from stays with the Atlantic Health System. The study group received an evidence-based home COPD Disease Management Program administered by a respiratory therapist with a patient- and family-centered approach.

About 12% of patients who received the at-home disease management program were readmitted to the hospital for exacerbation within 30 days of discharge. In comparison, approximately 22% who did not receive the intervention were readmitted within that time period. Significant differences favoring the therapy program were also found for 60- and 90-day readmission, reported Rupal Mansukhani, of Rutgers University in New Jersey.

COPD burden

COPD is the third most common cause of Medicare beneficiary readmissions, according to Mansukhani and colleagues. Fully 60% of patients return to the hospital within one year of discharge and 30% return within 3 months of discharge. What’s more, COPD exacerbations leading to hospitalization account for $13.2 billion of nearly $50 billion annual direct costs for COPD, they reported.

The Centers for Medicare & Medicaid Services in 2015 set limits on payments to hospitals with high readmission rates for COPD patients readmitted with exacerbation. 

The study team included representatives from At Home Medical, which provided the respiratory therapy services.

The study was published in the journal Respiratory Care.

Related articles:

Post-acute pulmonary rehab a net win for COPD patients, healthcare system

Poor sleep linked to more COPD flare-ups, NIH study finds

Better resident preparation and communication during the discharge process is the key for skilled nursing facilities hoping to reduce hospital readmissions and produce better outcomes, new study findings show. 

The conclusions were among the facility-specific interventions detailed by the United Hospital Fund in a new report released Monday.

“The difficulties that patients experience when transitioning home from care in a skilled nursing facility are only a small example of the lack of a comprehensive and sustainable long-term care strategy,” the report on improving transitions states.  

“While there are many challenges that need to be addressed when a patient is discharged from an acute care hospital to a SNF, a ‘warm handoff’ of the patient to the receiving health care provider is possible and has been identified as a successful transition of care strategy,” it added. 

The overall report followed eight skilled nursing facilities in New York over a two-year learning collaborative. Policies they put in place included improving medication education before discharge and improving patient education on chronic illness self-management. 

One SNF that started conducting follow-up calls within 72 hours of a discharge was able to improve patients’ self-reported understanding of medications improved from 60% to 94%. 

Another facility found that communication about a patient’s discharge plan among staff was inconsistent, so it assigned a single point person to oversee the plan. The SNF assessed patient satisfaction with the discharge plan through pre- and post-discharge surveys. 

“Over a four-month period, 91% of patients indicated pre-discharge that they were given educational materials and/or teaching about their diagnosis and management at home. This increased to 100% post-discharge, suggesting that gaps identified by the pre-discharge survey during the rehab stay were successfully addressed before discharge,” report authors noted. 

Researchers said these measures addressing communication breakdowns among SNF staffers and patient education could help increase patient confidence to manage their conditions and prevent being readmitted into a hospital. 

“The SNFs were all able to identify opportunities for improvement in their internal discharge planning processes that could benefit the patients and families they serve,” the report concluded.