Home From The Editor Heading off readmissions from post-acute care

Heading off readmissions from post-acute care

September 2013

Published in the September 2013 issue of Today’s Hospitalist

While everyone seems to be talking about readmissions “and strategies to appropriately avoid having patients bounce back “our cover story this month examines the issue from a different angle: readmissions from post-acute care.

Readmissions are a problem in all settings, but bouncebacks from post-acute facilities present their own set of challenges. While about 25% of all patients bounce back within 30 days, that number may jump to 40% for patients transferred to skilled nursing facilities.

A big problem is the way that hospitalists communicate with their post-acute care colleagues. When hospitals give SNFs way too much documentation “upwards of 60 pages of notes, according to one physician we interviewed “post-acute caregivers have a hard time getting their arms around what’s wrong with a patient and what goals the SNF is trying to reach in providing care. So if something is unclear, some SNFs simply send patients back to the hospital.

The good news is that hospitalists can take some simple steps to drive down readmissions from post-acute care. Physicians working in SNFs, for example, say that a targeted discharge summary with treatment goals is much more useful than a folder crammed with patient notes and the results of every lab test.

Some hospitalists are starting to experiment with strategies to better communicate, and there are signs that it’s paying off, in part through reduced readmissions. Just as hospitalists have worked hard to improve how they communicate with primary care physicians, the specialty needs to bolster outreach to post-acute care providers.

Some groups are going even farther by examining the role that hospitalists can play in staffing SNFs and other post-acute facilities. I’ve heard from hospitalists who say that working in post-acute care is a major case of mission creep, but there are signs that it may become the new normal.

edoyleEdward Doyle
Editor & Publisher