The Nursing Home and Hospital Readmission Cycle

According to a new study in the Journal of the American Geriatrics Society, hospitals and emergency departments readmit a significant proportion of Medicare Beneficiaries within 30 days of discharge from nursing homes. Researchers looked at a cohort of 55,000 Medicare beneficiaries aged 65 and older who were hospitalized, transferred to a skilled nursing facility (SNF) and then discharged home. The findings of the study demonstrated the ongoing vulnerability of older adults to poor outcomes after leaving the nursing home.In fact, approximately 22% of the Medicare beneficiaries cohort were rehospitalized within 30 days of discharge from the nursing homes, and 37.5% needed acute care within 90 days of discharge. Researchers also looked at different factors including race, gender and medical history to determine if certain populations were at a greater risk than others. They found that men, African Americans and older adults with respiratory diseases or cancer had a higher chance of being rehospitalized.

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Senior woman with her caregiver at home

“Nearly two million older adults use this [Medicare] benefit every year,” explained  Mark Toles, Ph.D., associate professor at the University of North Carolina at Chapel Hill and lead researcher for the study. “Before this study, we didn’t recognize the large number of older adults who require additional acute care after they’re discharged from a nursing home.” These findings suggest the need to increase support for beneficiaries as they transition from nursing homes to their own homes. While this study did not determine what proportion of the readmissions could be preventable and avoidable, it does indicate that more research is necessary to determine what factors will decrease the number of readmissions. According to Toles, “…the findings indicate that health outcomes after SNF discharge are multifactorial, related to individual and system characteristics, and will likely require a multipronged approach for future study and intervention.” Toles calls for more research to develop the right kind of services that improve the transition of care into the home, including services that better prepares family caregivers to assist after discharge.

There has been a lot of emphasis on improving the patient’s transition from the hospital to their home because under the Affordable Care Act, hospitals now get penalized for readmitting Medicare patients within 30 days of their discharge. Toles hopes the results of this study will convince health systems to focus on developing and implementing new strategies to improve care transitions from nursing home facilities as well.

Read the full study here


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