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Hospital Readmissions

​Target: By March 2, 2015 at 12:00 p.m., individual communities will safely reduce hospital readmissions by 15 percent (this includes any admitting diagnosis).  Individual communities that have less than 5 percent of residents with hospital readmissions will maintain  hospital  readmissions below 5 percent. 
 
Hospital readmissions not only have negative physical, emotional and psychological impact on these individuals, but also costs government programs like Medicare billions of dollars.
 
More can be done to prevent sending seniors back to the hospital while they receive care in assisted living communities.
 
How can assisted living communities achieve this goal?

Communities can achieve this goal by adopting the INTERACT program which will help improve communications between care providers and residents, as well as improving relationships between inpatient and outpatient providers. Some additional steps communities can take:

  • Ensure seamless information exchanges between providers through the use of electronic health records (EHRs) 
  • Engage providers at all points throughout the spectrum of care. This team-based approach can enhance discharge planning; improve the medication reconciliation process; and identify high-risk residents toward whom providers can target interventions. 
  • Expand the use of nurse practitioners
  • Use consistent assignment of staff to ensure that staff are familiar with residents’ normal patterns and characteristics so that they detect early changes in resident’s conditions before they lead to a hospitalization
  • Utilize the tools on the Quality Initiative for Assisted Living website
 

 Documents

 
 

 Resources

 

Please note that the SBAR, Stop & Watch, Measurement of Hospital Transfer Rates, and Change in Condition Cards are only parts of the overall INTERACT (Interventions to Reduce Acute Care Transfers) Program which is a comprehensive quality improvement program.  Until the new INTERACT program for ALC is developed; the INTERACT for Nursing Homes which can be used for ALC can be found here.

The INTERACT Project Team is revising the INTERACT program and tools to be used in Assisted Living with support from a CMS Innovations Grant.  NCAL will post links to those new assisted living tools as soon as they are available.

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