Effective Strategies to Prevent Hospital Readmissions from Long-Term Care Facilities
Implementing comprehensive transitional care programs with clear communication between providers is the most effective strategy to prevent hospital readmissions from long-term care facilities. 1
Core Prevention Strategies
1. Improved Transitional Care
- Establish dedicated discharge planners and transition coordinators 1
- Implement post-discharge follow-up calls to patients/residents
- Ensure clear communication with outpatient providers through detailed hospital discharge summaries 1
- Provide appropriate medical equipment, medications, supplies, and prescriptions at discharge 1
2. Medication Management
- Adjust glycemic targets for older adults to prevent hypoglycemia-related readmissions
- Implement medication reconciliation at all transition points
3. Telemedicine and In-Facility Care
- Reduce hospital visits through telemedicine or "hospital at home" programs 1
- Have physicians visit LTCF patients in the facility when possible 1
- Arrange for medication refills to be obtained by LTCF staff on residents' behalf 1
4. Post-Hospital Return Protocols
- Implement quarantine protocols for residents returning to LTCFs after hospitalization 1
- Designate specific areas/compartments for recently hospitalized residents 1
- Monitor returned residents closely for clinical deterioration
5. Evidence-Based Care Models
- Implement specialized intervention programs for high-risk patients 1
- Consider initiating appropriate treatments earlier for high-risk conditions 1
- Utilize nurse practitioners or specialists for in-facility care 2
6. Advanced Care Planning
- Implement advance care planning and goals of care discussions 2
- Provide palliative care interventions when appropriate 2
- Ensure care plans align with resident/family wishes regarding hospitalization
Implementation Framework
Risk Identification
- Identify high-risk residents (multiple comorbidities, recent hospitalizations, polypharmacy)
- Utilize both clinical referrals and computer-generated risk assessments 3
Facility-Level Preparation
- Train staff on early recognition of clinical deterioration
- Ensure adequate staffing levels and expertise
- Implement surveillance systems for monitoring resident health status 1
Care Coordination
- Establish partnerships with hospitals and primary care providers 4
- Create clear communication channels between care settings
- Designate staff responsible for care transitions
Quality Improvement
- Track readmission rates and analyze patterns
- Conduct root cause analyses of readmissions
- Adjust protocols based on findings
Common Pitfalls and Caveats
- Focusing solely on readmission metrics: This may inadvertently increase mortality if facilities avoid necessary hospitalizations 1
- Inadequate risk adjustment: Socioeconomic factors significantly impact readmission rates and should be considered 1
- Observation stays masking true readmission rates: Include observation stays and emergency department visits in tracking metrics 1
- Resource limitations: Financial barriers are frequently cited challenges for implementing comprehensive programs 4
- Lack of staff training: Ensure staff are well-versed in current transition research and practice 4
Special Considerations
- Socioeconomic disparities: Facilities serving disadvantaged populations may need additional resources 1
- Patient-centered outcomes: Consider quality of life and patient preferences alongside readmission metrics 1
- Preventive measures: Implement influenza vaccination and other preventive measures to reduce initial hospitalizations 2
- Access to IV therapies: Enhancing access to intravenous therapies within LTCFs can reduce hospital transfers 2
By implementing these evidence-based strategies with careful attention to facility-specific needs and resources, long-term care facilities can significantly reduce hospital readmissions while improving resident outcomes and quality of care.