INCREASING POST-DISCHARGE SUCCESS

Updated: Oct 9, 2019

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One of the most recent and significant rate reducing penalties CMS has imposed on Skilled Nursing Facilities is the 2% reduction based on Acute Hospital readmissions. SNF’s do have the opportunity to earn all or at least some of the 2% back by bringing their Acute Hospital readmission rate below the threshold. Good interdisciplinary clinical care while in the facility, understanding the key drivers of re-hospitalization, taking action on these drivers, and following-up with the patient, family, or caregiver can net positive results in care quality, patient satisfaction, and financial success.


Q: Is my facility responsible for the patient’s success after the discharge to home?

A: The short answer is yes. In many ways, the care you provide for the patient while at your facility sets them up for either success or failure once they leave and return home. There is so much going on with a patient while they are recuperating, they may not remember all of the instructions they’ve been given. Many may not have even understood the instructions to begin with. Health literacy is an emerging issue from a public health perspective. Sometimes very intelligent people have varying degrees of understanding their own health needs. Determining their ability to understand, comprehend, and follow through with care instructions is critical to their success at home, particularly if social support in the home is limited. There are many standardized tests that may be implemented which give you clear insights into a person’s ability to understand their own health needs. You may then be able to formulate and adapt a teaching and training plan that suits your patient’s best learning ability. Passing this information on to the next level of care through ope