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Readmissions may be reduced through effective skilled nursing facility-to-home transition strategies

Better SNF-to-home transitions are needed, both for the physical health of the patient and the fiscal health of the organization.

Jeff Lagasse, Associate Editor

Readmissions are a thorn in the financial sides of many healthcare organizations. The federal government penalizes hospitals with high 30-day readmission rates by withholding reimbursement, giving facilities an incentive to keep patients out of the hospital.

New research published in the Journal of Post-Acute and Long-Term Care Medicine shows that about one quarter of heart failure patients who move from a hospital to a skilled nursing facility and then to their home are readmitted to the hospital at some point, negatively impacting reimbursement.

Because of that, better SNF-to-home transitions are needed, both for the physical health of the patient and the fiscal health of the organization.

IMPACT

In addition to the high rate of readmissions linked to SNF-to-home transitions, the research found the readmission risk was highest in the first two days after discharge from the nursing facility. The longer the stay in the SNF, the more likely the readmission risk declined.

The next step is to examine the SNF-to-home transition, which is likely important due to the complicated nature of heart failure patients in particular, especially when compared to the overall Medicare population.

A comprehensive discharge planning process is needed because, during an SNF stay, adjustments are often made to medications, diets are tweaked and lab tests perform, all of which would benefit from some follow-up post-discharge.

SNF discharge procedures should mirror hospital best practices, researchers said. Medical reconciliation and a discharge summary describing the hospital stay are important components of a solid discharge plan, and SNFs should mirror those, according to the study.

THE TREND

Many strategies have emerged that are designed to put a dent in 30-day readmission rates. A new program designed to help heart attack patients with the transition from hospital to outpatient care can reduce readmissions and deaths and increase the number of patients keeping follow-up appointments, for example.

Twitter: @JELagasse

Email the writer: jeff.lagasse@himssmedia.com