Limiting avoidable rehospitalizations has received renewed emphasis from the Centers for Medicare & Medicaid Services in recent years.
Traditionally, hospitals have borne the financial brunt when patients are readmitted. However, beginning this year, therapy providers will begin being penalized as well when residents are rehospitalized.
So what can Skilled Nursing Facilities do to limit the number of readmissions for SNF residents—either while at the SNF or after discharge?
Let’s take a look.
Therapy Providers Limit Rehospitalizations by Implementing Multidisciplinary Care Plans
Studies show that single-component interventions are not effective in significantly reducing rehospitalizations among long-term care residents. This makes it highly important for SNFs to implement multidisciplinary plans.
And for optimal outcomes, therapy providers will also need to take preventive steps as early on as possible during residents’ stay.
With this in mind, through collaborative, coordinated care, SNFs can reduce the number of hospital readmissions for residents by:
- reconciling medications to improve medication adherence and reduce the risk of medication-related adverse reactions
- minimizing the use of urinary catheters and other similar built-in devices to reduce the risk of infections, and thus, rehospitalization
- including residents in care planning discussions to ensure the chosen therapies align with residents’ preferences
Overall, employing a resident- or person-centered approach to resident care, a chief focus of CMS’ new Final Rule, can go a long way toward limiting avoidable rehospitalizations among SNF residents.
In addition, therapy providers can help cut down on preventable readmissions by proactively addressing top causes of rehospitalization among residents.
Therapy Providers Limit Rehospitalizations Through Wound Management and Fall Prevention
Because SNF residents tend to be older, have multiple comorbidities, and are at an increased risk of cognitive or functional impairment, there is a wide variety of reasons that lead to the rehospitalization of residents.
But the two leading causes of rehospitalizations among SNF residents that therapy providers can take extra steps to prevent are wounds and falls.
Dedicated Wound Management
Pressure ulcers, in particular, are fairly common among residents and cause a number of rehospitalizations among the long-term care population. As such, special attention should be given to preventing and managing pressure ulcers.
There are three main ways therapy providers can help prevent pressure ulcers and other wounds from developing:
- implementing a physical activity regimen
- paying careful attention to positioning
- providing prompt attention to any skin changes
The first of these—encouraging physical activity—is particularly important. Through both physical and occupational therapies, residents can potentially:
- improve their mobility
- increase cortisol levels
- reduce inflammation
- boost blood flow and appropriate oxygen levels throughout the body
Additionally, therapy providers can also implement measures related to positioning, such as a turning/positioning schedule and using pressure-reduction devices as needed.
Prioritizing Fall Prevention Plans
Falls are also common among seniors, and are the leading cause of both nonfatal and fatal injuries for those age 65 and older. This makes fall prevention an essential part of limiting rehospitalizations.
Falls can result in fractures, head injuries, and other serious conditions, so developing a fall prevention plan is vitally important. These plans are typically drawn up at admission, when a fall risk assessment is performed.
In addition, therapy providers can help reduce the risk of falls, and, thus, rehospitalization, by carefully observing residents and their environment to identify any factors that could contribute to falls, such as:
- hazards in the room
- potential reactions to medications
- changes in state due to medical conditions
Through these observations and those of other providers on the residents’ multidisciplinary team, additional steps can be taken to limit risk.
There are times when rehospitalization is simply unavoidable for SNF residents. But there are also times when readmission can be avoided.
By developing a multidisciplinary plan, providing coordinated, preventive care, and proactively addressing leading causes of readmissions, therapy providers can limit the number of avoidable readmissions, and ultimately, improve resident outcomes.
Limiting rehospitalizations among SNF residents takes a team effort. Our rehabilitation services team works with your multidisciplinary team to mitigate key factors for hospitalization. Partner with us today by calling (412) 963-9698.