top of page


Updated: Oct 9, 2019

Written by,

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 open lines of communication with Home Health agencies, physicians, outpatient centers, etc., can aide in follow-through and a successful transition.

Q: What are some reasons my patients return to the hospital after they’ve left my facility?

A: There are so many possible reasons that issues can occur once they’ve transitioned home. It’s our responsibility to anticipate as many of those risk factors as possible, care plan them, then address and communicate regarding those risks as an interdisciplinary team. Through feedback from CMS and the SNF partners we serve, Concept Rehab has developed a return to hospital risk assessment that singles out 12 common potential factors which if left unaddressed, are likely to cause a re-hospitalization either during the SNF stay or once they’ve transitioned to their next level of care. These common risk factors are Medication Management, Manual Dexterity, Vision, Health Literacy, Caregiver Support/Availability, scheduled follow-up with Primary Care Physician, Cognition, Fall risk, Active infections, Vital signs, Pain, and Wound risk. Any one, or any combination of these issues place the patient at risk. We utilize standardized assessments to score and apply a risk value to each of these individually and as a whole. We’ve found through our research, this is a promising approach to identifying then reducing re-hospitalization risk.

Q: What can I do to support a successful patient transition to the next level of care?


  1. Understand and address the health related issues placing them at greatest risk for re-hospitalization.

  2. Identify whether or not the patient’s health literacy is going to impair their ability to follow-through with your team’s instructions. Adapt a teaching approach that meets your patient’s learning style.

  3. Begin planning for their transition from day 1 of their stay. Use evidence through standardized assessments to guide your approach to care planning.

  4. Communicate about the patient’s risk areas in your interdisciplinary process daily. How are they being addressed? Who’s responsible for addressing them? Which risks remain an issue? What are we doing to resolve, compensate, or adapt?

  5. Communicate with the providers at the next level of care. Invite them to participate in the discharge conference so they have an awareness of the patient’s needs and risk areas. This will save time and resources in having to identify the risks for themselves, often too late.

  6. Follow-up contact. Give the patient a call within 7 days of returning home. Ask specific questions about the areas you know placed them at re-hospitalization risk. If the patient shows any indication of decline or their success is in question, suggest readmitting them to your facility within their 30 days post-discharge skilling window. By doing so, you can address these issues in a lower cost care setting before an emergency room visit or readmission is required.



bottom of page