The Vital Role Skilled Nursing Facilities Play in Reducing Hospital Readmissions

Readmissions to hospitals are a crucial challenge for health care providers, particularly for patients discharged to skilled nursing facilities (SNFs) who then require unplanned acute care. These readmissions disrupt patient care continuity but are also responsible for billions of dollars in costs, which places more weight on already strained health care budgets. 

Approximately one in four Medicare beneficiaries discharged to an SNF is readmitted to a hospital within 30 days, according to recent studies. 

Understanding the role SNFs play in the larger equation is important when considering Medicare’s increased penalties for excessive readmissions under the Hospital Readmission Reduction Program.  

How Cost and Care Are Strained by Rehospitalization

Hospital readmissions are expensive and clinically costly. According to recent Centers for Medicare & Medicaid Services (CMS) data, 21% of over 1.5 million discharges resulted in hospital readmissions. Around 23.5% of patients discharged from acute-care hospitals to SNFs experience a readmission within just 30 days.

The average cost during that 30-day window is estimated at over $16,000 per patient. When totaled, these return visits cost an estimated $4.34 billion in annual costs. An estimated 78% of these readmissions are considered potentially avoidable.

These readmissions are not only expensive but compromise patient outcomes: they compromise patient safety, increase the rate of physical and mental decline, and decrease patient satisfaction.

Factors That Increase Hospital Readmission Rates

The transition from hospitals to SNFs is important to the care continuum, but often challenging due to many related factors:

Staffing Levels and Quality: Nursing staff ratios directly influence patient outcomes. Care facilities with lower staffing levels or issues with inconsistent staffing have higher rates of hospital readmission.

Patient Demographics and Clinical Complexity: Patients who transfer from hospitals to SNFs typically have many chronic conditions, complex medication regimens, and require a high level of care. These complexities, combined with other issues, increase readmission risk.

Gaps in Communication and Coordination: Poor communication between institutions can often lead to medication errors and a disruption in continuity of care. Effective and meticulous communication is important to ensure quality care and reduce errors.

Quality of Care: Facilities that performed well compared to standardized benchmarks, such as the CMS Five-Star Quality rating system, tend to improve patient outcomes. Plus, hospitals that participate in value-based care and shared-savings programs, such as the SNF Value-Based Purchasing and Incite Workforce Solutions Program, experience better patient continuity and patient outcomes.

How to Reduce Rehospitalization from Skilled Nursing Facilities

Hospitals and SNFs can implement evidence-based strategies to decrease the likelihood of readmissions.

Establish Structured SNF Networks and Partnerships: Studies show that hospitals partnering with high-quality SNFs see significant reductions in readmission rates. Implementing these strategies led to Mount Sinai experiencing a 20% drop in readmissions.

Improve Nurse Staffing Ratios and Training: Comprehensive training programs and adequate staffing can improve the quality of care provided to patients. Higher nurse-to-patient ratios and continued education reduce readmissions and improve patient satisfaction.

Implement Predictive Analytics and Care Coordination Tools: Leveraging these care tools allows for proactive management for those at risk of rehospitalization. Predictive staffing platforms, like Booker powered by SnapCare, benefit from more efficient planning and improved patient outcomes.

Provide Discharge and Transition Planning: Ensuring that patients understand their post-discharge instructions significantly decreases avoidable readmissions by empowering patients and decreasing their anxiety.

Engage Patients and Families in the Transition Process: Leveraging patient-centered communications – like teach-back techniques – improves adherence to care plans and reduces preventable readmissions.

Leverage continuous quality Improvement Programs: SNFs that implement quality improvement programs like INTERACT (interventions to Reduce Acute Care Transfers) experience reductions in readmissions. These programs involve regular monitoring and audits to help SNFs sustain ongoing improvements.

Read more in the full article by Jeff Richards, the CSO and Co-Founder of SnapCare.