Research shows that many hospital readmissions are avoidable. Yet, in 2022, about 75% of hospitals still incurred readmission penalties. In 2021, only 1 in 5 Skilled Nursing Facilities (SNFs) were awarded payments from the SNF VBP (Value-Based Purchasing) Program based on hospital readmissions.
The SNF VBP program expansion will include Discharge to the Community-Post Acute Care Measure and the SNF Within-Stay Potentially Preventable Readmission Measure as well as others. This emphasizes that care coordination (good communication) between care settings is imperative, not only for an organization’s bottom line, but for the patient/resident’s well-being and safety.
Often times, the root cause of an avoidable hospital readmission is a communication gap. A lack of communication from the long-term care facility/SNF, home health organization can result in the patient/resident going home with a limited understanding or knowledge of their instructions by the discharging organization (hospital, LTC/SNF, home health). In our rush to discharge the patient/resident to one care setting to another or to home, we often forget that we need ensure the person or their caregiver fully understands how to care for themselves or the person they are caring for. If not done properly, we create a cycle of lack of knowledge, understanding, hearing, teaching, and listening.
The Re-Engineered Discharge (RED) Toolkit can be used to help improve discharge processes. The RED toolkit includes tools to better understand the role of culture, language, and health literacy in readmissions. We can work to communicate better and to create policies for use of warm hand-offs with every transfer, including every discharge. These warm hand-offs have proven to reduce readmissions when discharging to another level of care.
The Agency for Healthcare Research and Quality (AHRQ) states that 40 – 80% of the medical information patients and residents are told during office visits is forgotten immediately and nearly half of the information retained is incorrect. Teach-back is a technique for health care providers to ensure that they have explained medical information clearly so that patients and their families understand what is communicated to them. It involves asking patients/residents to recall and explain or demonstrate the important information discussed during an interaction with their healthcare team.
“Recently my mother went to her doctor. After her appointment, she said, ‘Dr. T did something she had not done before, and it was great! She had me tell her the new medicine she was starting me on. She had me explain the name, dose and how often I was going to take it after she explained it to me. It was like she wanted to make sure I heard her right; I understood so much better because she took the time to do that,” shared Tammy Wagner, Great Plains QIN Quality Improvement Advisor.
The Great Plains QIN team created a Teach-Back Training Toolkit to assist in teach-back education and training for your team. Many of these documents can be modified to meet your needs. Access the Toolkit on our Web site (found on the Teach-Back Training accordion).
One way to help reduce readmissions is for hospitals, nursing facilities, home health organizations, clinics, EMS, and other long-term community support services to work together. Collectively we can to identify needs and better support individuals with mental/behavior problems, substance use disorders (SUD), those with transportation and social isolation issues, and individuals with food insecurity. With stronger communication with staff and with our patients/residents, we can avoid hospital readmissions, and reduce confusion with the people we are trying to care for.
Access our Focus 4 Health Series Resources
November 2023 | TeamSTEPPS® – Improving Communication and Teamwork Skills
July 2023 | Multi-Visit Patient (MVPs) – Reducing Preventable ED Visits
- Multi-Visit Patient (MVP) Method & Implicit Bias Connection I Recording
- Utilizing Community Health Workers (CHW) to reduce MVPs | Recording
- Reducing Avoidable ED Visits by Working Together in the Community | Recording
- Coordinating Care, Communication, and Trust is a Must to Help MVPs | Recording
February 2023 | Reducing Avoidable Emergency Department Visits
- Reducing Avoidable Emergency Department Visits | Recording
- Communication During Hand-Off’s I Recording
- Communication Strategies I Recording
- Infections, Falls, Medications, Success Measurement & Celebrating I Recording
Listen to Our Podcast – Q-Tips For Your Ears
MVP-Multi-Visit Patient and Teach-Back Communication: Good communication is essential to help patients stay out of the emergency department and hospital; avoiding the ‘Multi-Visit Patient – MVP’ label. Take a few minutes to listen and learn more.