Ending Hospital Readmissions: A Blueprint for SNFs

Ending Hospital Readmissions: A Blueprint for SNFs Avoid the pitfalls that cost SNFs billions each year in preventable rehospitalizationsAn informed and proactive nursing home staff is a vital weapon in the struggle to keep residents from being readmitted to the hospital. "Ending Hospital Readmissions: A Blueprint for SNFs" delivers several practical strategies your facility can employ to combat this problem, such as enhanced resident assessment and documentation policies, provider partnerships that improve transitions of care, staff education tools, and methods to achieve resident and staff involvement. This book will show you the true financial consequences of unchecked resident readmission and provide you with the tools to do something about it!The information in this book will help you develop a plan to: Ensure smooth care transitions through resident education and effective communication with staff and other care providersReduce costs associated with rehospitalizationsPrevent the incidence of hospital readmissions resulting from avoidable complications, medication problems, and adverse eventsEncourage the resident and family to participate in the transition to ensure satisfaction with quality of careMaintain or improve the resident's quality of lifeTable of Contents Chapter 1: Introduction Why Are Hospital Readmissions a Problem? Medicare and Senior HealthcareRehospitalizationImplications of RehospitalizationsRehospitalization and RevenueThe Patient Protection and Affordable Care ActTransitional CareThe Bottom LineWhy Should I Care?Where to BeginChapter 2: Identifying the Origins and Causes of Problematic Transitions Interfacility CommunicationLong-Term Care Facility ConcernsPhysician ConcernsSchedule Drug IssuesEmergency Department ConcernsPatient and Caregiver ConcernsSurprising InformationChapter 3: Reasons for Inappropriate Hospitalization and Rehospitalization Most Common Causes of Inappropriate RehospitalizationFinancial IncentivesEarly DischargeThe Weekend ExodusMedical Diagnoses and Conditions That May Predispose Residents to Acute Changes in ConditionNew Onset Problems Suggesting an Impending Change in ConditionChapter 4: Risk Factors Identifying Risk FactorsThe Polypharmacy ProblemMedication ReconciliationThe Patient Self-Determination ActHospice CareChapter 5: Medicare Part A Basics The Medicare ProgramObservational Hospital AdmissionsMedicare Paperwork in the HospitalInpatient Medicare Coverage and the SNFMedicare Level of Care and the Long-Term Care FacilityImportant Reimbursement IssuesTrend SettingDocumentationChapter 6: Strategies to Avoid Rehospitalization for Caregivers Avoidable Readmissions to the HospitalStrategies for Reducing Avoidable ReadmissionsStandard of Care for Monitoring Residents With Acute Illness or InfectionInitial Assessment and Documentation Guidelines for Conditions for Which Monitoring Is RequiredSpecific Responsibilities24-Hour Change of ConditionChange of Condition CommunicationChapter 7: Strategies to Avoid Rehospitalization for Managers Managerial Information for Reducing Acute CareTransfersFacility Admissions and ReadmissionsCommitmentEstablishing or Modifying a Facilitywide ProgramPhilosophy of CareDirector of NursingManaging Potential Barriers to SuccessChapter 8: Ensuring a Smooth Transition Transition InitiativesResident-Centered TransitionsReadiness for DischargeRisk for SNF Readmission or RehospitalizationPre-Transition IssuesRisks Associated With Poorly Executed TransitionsPreparing PaperworkAdvance DirectivesMedicationsPreparatory ActivitiesCoordination With OthersHome DischargesSteps to Take Immediately Before DischargePost-Discharge ActivitiesAudienceDON, CNO, MDS coordinator, director of rehab, therapy director, administrator."