Every player in the acute and post-acute care continuum are focused on reducing Return To Hospitals (RTH) rates. Not only does RTH impact the resident in a negative manner, but it also impacts the provider with poor client ratings and now possibly financial penalties. While Medicare has been leading the way in this area, the Managed Care/Insurance plans are also heavily focused on this subject. SNFs have better control while the patient is in the facility, but what about post discharge? What can SNFs do better to reduce the RTH rate after they left our care.
Consider engaging the Primary Care Physician (PCP) in the community upon their patient admission. By contacting the PCP, you are opening conversations regarding patient care, alerting them that the patient was in the hospital and now in SNF. Often the PCP is not aware of the patient’s change of condition and situation. During this communication, you could also attain their preferred Home Health Agency and who to speak to regarding potential referrals for outside services. This information will also help your team during the stay as well as upon discharge.
Upon discharge of the patient, providing the DC summary and medication reconciliation to the PCP will also assist in the preventing a RTH. A high percentage of RTH issues are related to medication errors. While home health does do this activity, it is important to close the loop with the PCP as well. In addition, partnering with home health agencies to communicate back to the SNF about patient issues will provide opportunity to readmit the patient to SNF (as appropriate) and divert from the ER. Following up with these entities will help with continuity of care and will result in additional referrals by being a good partner. Addressing the full continuum helps to treat the patient as a whole as opposed to just treating the patient for their admitting diagnosis.