Nurse walking with an elderly woman

In August 2017, Patti Baicy, the director of the clinical resources team for McKesson Medical-Surgical Extended Care, shared insight as to how post acute care providers can improve clinical operations to offer an excellent level of care and avoid the financial implications of not doing so. Beginning in October 2017, Skilled Nursing Facilities and post-acute care providers are required to publicly report their 30-day hospital readmission rates and are imposed penalties for high readmission rates.

Baicy offered 5 ways post-acute care providers can minimize hospital readmissions, which are summarized below:

 1. Patient assessment. The acuity level of patients being discharged from a hospital to a post-acute care setting is higher now than it’s traditionally been. Hospitals are not keeping patients longer than needed and are discharging them with medical needs that can be safely addressed in a non-acute care setting. The patient assessment processes and skills in the post-acute setting must be as effective as possible.

2. Care planning. CMS requires each patient to have a care plan written within 48 hours of admission to a post-acute care setting. The care plan, though, is only as good as the patient assessment, which dictates how the patient will be treated. The assessment should measure each patient’s risk of readmission based on his or her medical condition. The care plan should aggressively address the clinical risk factors that, left unattended, could send the patient back to the hospital.

3. Early intervention. Given their higher acuity, comorbidities and clinical risk factors, the medical condition of patients in post-acute care settings can deteriorate quickly and without obvious warning signs. The result is a return—and potentially preventable—trip to the hospital. Post-acute care providers must improve their ability to detect changes in a patient’s condition as early as possible and intervene before the condition worsens.

4. Care coordination. Medical research continues to show a correlation between avoidable hospital readmissions and poor patient handoffs and care coordination among providers. The discharge of a hospital patient to a nursing home is an example of a transfer that, if done well, can reduce the chances of a preventable readmission. If done poorly, the chances of returning to the hospital are much greater. One specific area that post-acute care providers should focus on is medication reconciliation.

5. Staff competencies. Post-acute care providers must hire, train,  educate and develop employees who excel at the following four competencies:

  • Assessing the health status and readmission risk of patients
  • Writing and executing care plans that improve patients’ health status and reduce their risk of readmission
  • Using diagnostic skills, complemented by medical technologies, to detect changes in patients’ conditions and intervene as early as possible
  • Using personal and digital tools to drive care coordination

McKesson adds that pursuing these strategies will likely increase operating costs. But if efforts are successful, post-acute care providers can realize a substantial return on investment as value-based reimbursement models reward them for keeping patients as healthy as possible and out of the hospital.

Access the August 14 McKessen Blog Post

The Great Plains Quality Innovation Network offers outreach, education and technical assistance in reducing avoidable hospital readmissions. We are partnering with practitioners, pharmacists, system leadership as well as consumers of care. If you are interested in getting involved and learning more, visit our Web site and join our Learning and Action Network today.

Source: McKessen Blog. Author: Patti Baicy; August 14, 2017