Name
Chamberlain University
NR-706: Healthcare Informatics & Information Systems
Prof. Name
Datea
Hospital readmissions in post-acute care facilities remain a pressing concern, as they compromise patient outcomes and place financial strain on the healthcare system. Readmitted patients are at higher risk for complications such as malnutrition, cognitive decline, recurrent falls, delayed functional recovery, and in severe cases, mortality. In the United States, over 16,000 skilled nursing facilities (SNFs) provide services to nearly 1.35 million individuals each year. These facilities deliver diverse forms of care, including skilled nursing, rehabilitation, and assistance with both activities of daily living (ADLs) and instrumental activities of daily living (IADLs) (Centers for Medicare & Medicaid Services [CMS], 2019).
While many residents transition into long-term care, a considerable proportion enter SNFs for short-term rehabilitation before returning to their homes, often supported by home health services. However, the burden of hospital readmissions persists, delaying recovery, increasing healthcare costs, and exposing patients to avoidable risks (CMS, 2019).
The table below highlights the most common factors contributing to readmissions and their subsequent impact on patient outcomes:
| Contributing Factors | Impact on Patient Outcomes |
|---|---|
| Cognitive impairments | Heightened confusion, decreased independence, and elevated safety risks |
| Sepsis | Severe infection, prolonged hospitalization, higher mortality risk |
| Increased falls | Injuries, fractures, loss of functional independence |
| Feeding difficulties/low appetite | Malnutrition, slower healing, and functional decline |
| Death | Preventable but fatal outcomes |
These outcomes underscore the need for implementing evidence-based interventions that proactively reduce hospital readmissions in post-acute care settings.
Data reveal that patients discharged to SNFs have a readmission rate of 17.8%, compared to 15.8% among those discharged directly home (UpToDate, 2019). Considering the 35 million hospital discharges annually in the U.S., these unplanned readmissions account for an estimated $15–20 billion in healthcare costs each year.
Although Medicare policies and financial penalties have incentivized improvements, readmission rates remain high. Between 2003 and 2007, nearly 20% of Medicare beneficiaries were readmitted within 30 days of discharge (UpToDate, 2019). These statistics highlight the importance of aligning clinical practices with evidence-based guidelines to reduce unnecessary hospitalizations.
As a Doctor of Nursing Practice (DNP) scholar, my role includes:
Identifying and addressing gaps between clinical guidelines and real-world practice.
Designing and testing evidence-based interventions that minimize preventable readmissions.
Enhancing patient quality of life by strengthening post-acute care delivery models.
In post-acute care, how does frequent rounding and oversight by clinical providers on newly admitted patients, compared to the current guideline recommendations, influence hospital readmission rates over an 8-week period?
Currently, CMS recommends provider visits every 30 days or as clinically necessary. In contrast, acute care hospitals conduct daily multidisciplinary rounds, which allow for earlier detection of complications. Unfortunately, in SNFs, patients often deteriorate under infrequent supervision, leading to late recognition of health decline and avoidable transfers back to hospitals (CMS, 2019).
Implementing more frequent provider rounds—at least two to three times per week—can promote timely recognition of complications, enable early interventions, and ultimately reduce readmissions.
A review of the literature identified several strategies proven effective in lowering readmission rates. Key findings from selected studies are summarized below:
| Author/Year | Focus of Study | Key Findings | Implications for Practice |
|---|---|---|---|
| Hatipoğlu et al., 2018 | Predicting 30-day readmission in pneumonia cases | 330 of 628 patients aged ≥65 were readmitted within 30 days. Strong discharge planning lowered risks. | Encourages individualized discharge planning and use of predictive risk assessment tools. |
| March & Mennella, 2018 | Quality improvement in long-term care | Poor staffing ratios strongly linked to higher readmissions. | Supports the need for better staffing, continuing education, and safe nurse-to-patient ratios. |
| Dadosky et al., 2018 | Telemanagement of heart failure patients | Telemonitoring reduced rehospitalizations by 29% with a 6.51% absolute reduction. | Telehealth provides cost-effective monitoring and supports early detection of complications. |
| Agarwal & Werner, 2018 | ACO participation and outcomes | ACO participation reduced readmissions by 1.7%, Medicare costs by $940, and 3.1 fewer hospital days. | Demonstrates value-based care benefits for both cost savings and improved outcomes. |
Summary of Evidence:
Collectively, these studies demonstrate that enhancing monitoring practices, improving staffing levels, leveraging telehealth technologies, and participating in value-based care models all contribute to reducing readmissions and improving patient safety.
The reviewed studies were largely rated as Level III evidence, representing good quality research with practical implications. Although limitations exist—such as small sample sizes and heterogeneity of study designs—the consistency of findings supports multifaceted approaches to lowering readmissions.
Key strengths include their real-world applicability and focus on interdisciplinary solutions. However, gaps remain in large-scale randomized trials examining the direct effect of increased provider rounding in SNFs. Future research should aim to bridge this gap.
Successful implementation of these interventions requires overcoming multiple barriers, including staffing shortages, financial limitations, regulatory constraints, and patient non-adherence. A team-based approach is vital to address these challenges effectively.
| Stage | Action Steps |
|---|---|
| Unfreezing | Identify the need for change; engage staff and leadership; highlight cost/quality concerns. |
| Changing | Implement frequent provider rounds (2–3 times weekly), enhance nursing education, and encourage daily team huddles. |
| Refreezing | Reinforce practices through policies, integrate monitoring tools, and establish a culture of proactive care. |
Lower readmission rates.
Improved patient safety and functional recovery.
Strengthened care coordination among providers, nurses, and allied health professionals.
Long-term sustainability of evidence-based care models.
Post-acute care facilities are essential to recovery following hospitalization, yet high readmission rates undermine care quality and strain healthcare systems. Evidence suggests that frequent provider rounding, robust staffing support, integration of telehealth, and value-based care initiatives can significantly reduce readmissions.
As a DNP-prepared nurse, advocating for and implementing these evidence-based interventions is crucial to fostering sustainable improvements in patient safety, quality of life, and cost-effective care in post-acute settings.
Agarwal, D., & Werner, R. M. (2018). Effect of hospital and post-acute care provider participation in accountable care organizations on patient outcomes and Medicare spending. Health Services Research, 53(6), 5035–5056. https://doi.org/10.1111/1475-6773.13023
Centers for Medicare & Medicaid Services (CMS). (2019). Skilled Nursing Facility 30-Day Potentially Preventable Readmission Measure (SNFPPR). https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=2801
Dadosky, A., Overbeck, H., Barbetta, L., Bertke, K., Corl, M., Daly, K., … Menon, S. (2018). Telemanagement of heart failure patients across the post-acute care continuum. Telemedicine and e-Health, 24(5), 360–366. https://doi.org/10.1089/tmj.2017.0058
Harris, C., Garrubba, M., Melder, A., Voutier, C., Waller, C., King, R., & Ramsey, W. (2018). Sustainability in health care by allocating resources effectively (SHARE) 8: Developing, implementing and evaluating an evidence dissemination service in a local healthcare setting. BMC Health Services Research, 18(1), 151. https://doi.org/10.1186/s12913-018-2958-3
Hatipoğlu, U., Wells, B. J., Chagin, K., Joshi, D., Milinovich, A., & Rothberg, M. B. (2018). Predicting 30-day all-cause readmission risk for subjects admitted with pneumonia at the point of care. Respiratory Care, 63(1), 43–49. https://doi.org/10.4187/respcare.05719
Manchester, J., Gray-Miceli, D. L., Metcalf, J. A., Paolini, C. A., Napier, A. H., Coogle, C. L., & Owens, M. G. (2014). Facilitating Lewin’s change model with collaborative evaluation in promoting evidence-based practices of health professionals. Evaluation and Program Planning, 47, 82–90. https://doi.org/10.1016/j.evalprogplan.2014.08.007
March, P. P., & Mennella, H. D. A.-B. (2018). Quality improvement in long-term care. CINAHL Nursing Guide. EBSCOhost. https://search.ebscohost.com
McBride, S., & Tietze, M. (2018). Nursing informatics for the advanced practice nurse: Patient safety, quality, outcomes, and interprofessionalism (2nd ed.). Springer Publishing.
UpToDate. (2019). Hospital discharge and readmission. https://www.uptodate.com/contents/hospital-discharge-and-readmission
Burke, R. E., Jones, C. D., Hosokawa, P., Glorioso, T. J., Coleman, E. A., & Ginde, A. A. (2020). Influence of transitional care interventions on hospital readmissions: A meta-analysis. Journal of General Internal Medicine, 35(7), 2084–2093. https://doi.org/10.1007/s11606-020-05715-2
Kim, H., Park, J., & Kang, H. (2021). Telehealth interventions for reducing hospital readmissions in chronic disease: A systematic review and meta-analysis. International Journal of Nursing Studies, 118, 103923. https://doi.org/10.1016/j.ijnurstu.2021.103923
Ouslander, J. G., & Grabowski, D. C. (2020). Reducing hospitalizations from skilled nursing facilities. Health Affairs, 39(11), 1859–1866. https://doi.org/10.1377/hlthaff.2020.00724
Wang, Z., Yuan, Y., Guo, Y., & Li, H. (2022). The effectiveness of nurse-led transitional care programs in reducing hospital readmissions: A systematic review and meta-analysis. BMC Nursing, 21, 51. https://doi.org/10.1186/s12912-022-00832-9
