How are you decreasing readmission rates??

CoffeeRTC, BSN, RN · Jan 31, 2012

I'm a LTC nurse but stumbled on this thread. We do a mostly skilled care with short term stay (but have a wing of traditional LTC residents)

My two cents...make sure if you are d/cing them to a SNF that the place is able to take care of them and have the resources available. I understand that it is the facility's fault (or the person accepting the admit) when we get really, really complex patients that require more care than we can give but that is one of the biggest reasons we send a person back to the hospital.

People are getting discharged faster and sicker. We can handle acutly ill people, but not all the time. Most LTCs have satalite pharmacies that take 1 to 3-4 hrs for stat meds, xray, lab and IV services are the sameway.

When these people come to us they have unrealistic expectations and assume they are going to be getting the same type of care as in the hospital. There are no docs in the facility unless they are doing weekly rounds. Nurses have on average 20 patients. (I know it isn't better in the hospitals)

Pt education.....we get alot of people that really truely are clueless as to what was treated while in the hospital. Diabetes is the big offender. Totally understand that it is going to take more time than the time they are in the hospital to teach this, but the very very basics could have been reviewed.

onthego22 · Jan 31, 2012

Our discharge process is not good and Ithink that is our biggest problem. Along with educating the patients. And you are absolutely right about sending them to SNF's. They are getting more complex...especially the wounds and all of their co-morbidities. Sometimes, there is such a push on decreasing the LOS that we think getting them to a SNF would solve our problems. Not so. We are trying to come up with a plan...right now we are running some demographics to find out who our biggest offenders are and then go from there. But would love some ideas on how others are reducing their readmissions.

SummerGarden, BSN, MSN, RN · Feb 2, 2012

Are you focusing on all core measures, folks with co-morbidities, etc. Do you have any programs in place?
Also, any programs in place for infectious disease? We have a very busy wound clinic with NO case manager/social worker. We need a way to help facilitate early discharges, decrease LOS and readmissions, etc. We are lobbying for a CM/SW in this area but we need some ideas :)
Thanks!

Are you starting from scratch? If so, you sound like you have the right ideas (a need for programs that target comorbidities and high risk disease management issues and a need to hire CMs and MSWs). Be sure to also hire a Manager/Director of the CMs and MSWs that has experience in this area plus CMs and MSWs that have experience too. Otherwise, your program will not be very effective. GL!

onthego22 · Feb 2, 2012

About a year ago we increased the number of case managers. We have just hired a new director and hopefully things will improve. Right now we are looking at our readmissions and trying to figure out what we can do within the hospital and outside. I didn't know if anyone out there has any programs established that are working.