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Discharge Back to the Community



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​Skilled nursing centers are responsible to assist individuals in improving functional independence and adequately prepare individuals for discharge from the center.  Assuring individuals and their families are able to manage care needs after discharge to home or another community setting is important to prevent rehospitalizations.   
 
The Medicare Payment Advisory Commission (MedPAC), the IMPACT Act and changes to the Five-Star Quality Rating System all call for measuring discharges back to the community, not to mention its importance for managed care plans, ACOs, and bundled payment models.  This measure focusses on the proportion of patients admitted from a hospital to a skilled nursing center who are discharged back to the community within 100 days.   

 

A number of tools and resources are available to assist member organizations in accomplishing the goals of the Quality Initiative.  Members are encouraged to use the following resources:

AHCA measures progress for this goal by using a risk-adjusted MDS based measure developed by Brown University, which has been added to LTC Trend Tracker(SM).

For the latest progress data, click here.

Members are encouraged to run their Discharge to Community report in LTC Trend Tracker sm to see if they are above or below the national average.  Not sure if your organization uses LTC Trend Tracker?  Please email help@ltctrendtracker.com and request the name of your account administrator. 

 

​​DISCLAIMER: The AHCA/NCAL quality programs’ contents, including their goals and standards, represent some preferred practices, but do not represent minimum standards or expected norms for skilled nursing and/or assisted living providers. As always, the provider is responsible for making clinical decisions and providing care that is best for each individual person.

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