4 Ways to Prevent Hospital Readmissions

It’s an expensive time to be a skilled nursing facility. In an effort to improve patient care and transition SNFs from a fee-for-service to a value-based payment plan, federal mandates now call for up to a 2 percent cut in Medicare payments to facilities with high 30-day hospital readmission rates. Of the nearly 15,000 SNFs monitored across the country, a whopping 73 percent received penalties in 2018.


Not only do hospital readmissions invite fines from CMS, but they can also be extremely costly to a skilled nursing facility (SNF) in other ways. They are likely to spur a chain of events that starts with higher patient care costs and leads to a loss of referrals from hospitals and providers, scrutiny by commercial payers, and a poor reputation with consumers. Coupled with the heavy penalties from CMS, these increased costs could really affect a facility’s bottom line.

All the more reason for SNFs to look for ways to improve their hospital readmission rates and avoid the associated costs in 2019. You can start by focusing on patient engagement, evaluating social determinants, follow-up calls, and staff competencies.


1. Patient Engagement

Patients and their loved ones are oftentimes faced with uncertainty when it comes time to leave the safety net of an SNF. Rather than overwhelm them with instructions and information on the day of discharge, start a discharge plan and educate your patients throughout their stay. On the day of discharge, spend adequate time thoroughly reviewing instructions and confirm the patient and their caretaker both understand. An extra hour spent during discharge is significantly less expensive than a hospital readmission a week down the road.

2. Evaluate Social Determinants

Social determinants—such as income, education level, living conditions, transportation access, and support networks—also play a significant role in hospital readmissions. Many experts say social determinants impact health more than medical status does. Screen for at-risk patients upon admission and then place resources where necessary to help with the social determinants.

3. Patient Follow-Up Calls

The period immediately following discharge is a vulnerable time for patients—one in which swift changes can occur. Following up with patients and their caregivers with a phone call soon after discharge can decrease confusion and reinforce follow-up plans. Post-discharge phone calls allow the SNF to identify and remedy any gaps that may pop up between admission and discharge. They also allow providers to emphasize key elements of the discharge instructions, medication changes, and follow-up plans. If you'd like to learn more about how Cortex can help you with your follow-up calls, contact us here.

4. Nursing Staff Competencies

Knowledge and competency are not the same things. Having a competent staff means they have knowledge and skills and are able to transfer both into intended and measurable outcomes. Without a competent staff, none of the aforementioned tactics can be accomplished to fidelity. Quality care is crucial to the success of an SNF, and having a competent staff is crucial for quality care.

Reducing avoidable hospital readmissions offers a significant opportunity to reduce cost and improve the patient experience simultaneously. SNFs can also realize a substantial return on investment as value-based reimbursement models reward them for keeping patients as healthy as possible. So this year, be sure to focus on patient engagement, evaluating social determinants, follow-up calls, and staff competencies. Then CMS fines will quickly be a thing of the past.

Want to know how Cortex can help?