Hospital readmissions continue to be frequent despite their negative impact on health outcomes and financial strain on the health care system overall. On average, 14.56 percent of patients across the nation who have been discharged from a hospital, whether to a post-acute care facility or a home, will be readmitted for unforeseen circumstances. Readmissions can be triggered for various reasons and may be inevitable, yet some could be easily avoided with adequate staffing and care coordination.

Readmissions pose additional risks to patients as they are re-exposed to various diseases and illnesses while also being set back in their care regimen. On top of the health risks, they also cause distress to the patient and their families, along with a large price tag. Over $52.4 billion is spent annually on hospital readmissions, averaging over $15,000 per patient. Given these impacts, the US government has set standards aimed at preventing readmissions. Some of the programs include the Hospital Readmission Reduction Program and the more recent Minimum Staffing Standards for Long-Term Care Facilities.

While these programs are a step in the right direction, many organizations are still suffering from staffing shortages, with 72 percent of skilled nursing facilities (SNFs) stating that their current staff level is lower than it was prior to the pandemic in 2020, according to one survey. While these organizations continue to battle the staffing shortage, the inability to meet the requirements of the new CMS programs could result in facility closures across the nation, triggering even more readmissions for those who aren’t able to receive the necessary care due to a lack of SNF beds. Many hospital and SNF facility leaders are left wondering one thing – what can be done to reduce hospital readmissions in my facility?

Data-driven care delivery

Utilizing data insights to gain a real-time view of patients’ conditions, especially those with chronic illnesses, can be a tremendous help in preventing readmissions in post-acute care facilities. Health systems can use patient monitoring, tracking, and reporting technologies to identify early signs of deterioration, better understand patient progress, and enhance communication and transitions of care between the SNF, hospital, and primary care provider. Through this, predictive analytics can be generated to help staff better understand patients and anticipate their needs.

This becomes increasingly helpful with the heightened focus on reducing readmissions, as these analytics can highlight which patients are deemed the highest risk for readmission. Staff can then ensure these patients are closely monitored and receive the proper care. Providers can continue updating patients’ progress throughout their stay to ensure the information follows them throughout the rest of their health care journey.

Cohesive communication

While tracking patient progress is important, assuring the information is accurately shared across a patient’s health care ecosystem is also critical. A patient’s ecosystem consists of various practitioners and specialists at different facilities and can become very overwhelming and disorganized based on the severity of an individual’s medical history. Streamlining communication across providers becomes key to preventing hospital readmissions. For example, a patient admitted to a SNF after a hospital stay has their recovery tracked by the hospital case manager, SNF staff, SNF physicians, and ideally, their primary care provider in the outpatient setting. If these parties are not effectively communicating with each other, there is significant potential for errors in care delivery and, ultimately, readmission as the patient’s condition is exacerbated.

Given the importance of communication, tracking patient progress in one localized system will help ensure that each party knows how the patient is doing overall. This will also allow primary care providers in the outpatient setting who may be more familiar with their patients in a short-term SNF stay to share suggestions on medication management or treatment plan recommendations. It will also help the shorthanded staff treat their patients more quickly rather than spending an uncertain amount of time digging through files and asking questions the patient may not know the answer to.

Care coordination

Providers should establish a robust care coordination plan prior to a patient being discharged to their home from a post-acute facility or hospital. Once at home, some patients may continue to receive assistance from family members or caregivers who must be aware of specific care regimens to make the transition as smooth as possible. This may involve tracking vitals, administering proper medication doses at the correct time, or continuing rehabilitation exercises.

For individuals living alone and caring for themselves post-discharge, their care regimen must be clear to them before leaving the facility. Setting up reminders or using pill organizers prior to discharge can be a helpful place to start. Having nurses from a facility or a primary care provider complete frequent check-ins can also help promote proper care. Those completing the check-in can ask indicating questions to help determine if a person is having further complications, therefore allowing intervention prior to a readmission incident.

Streamlined care for readmission reductions

Decreasing hospital readmission rates is a complex challenge with no easy solutions. To ultimately improve the health of patients across the nation, cohesive communication throughout a patient’s health care journey and ecosystem is necessary. Utilizing available technology within health systems to track patients’ progress will not only draw attention to those who are at the highest risk of readmission but will also allow providers and other physicians to understand an individual’s health journey to make informed decisions in the future. Streamlining the tracking process will ensure that everyone who is part of a health care ecosystem is aligned and will make the transition out of facilities as smooth as possible, reducing readmissions overall and ultimately improving health outcomes.

Ahzam Afzal is a health care executive.