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Reducing Hospital Admissions

Readmissions the Topic of the Day for Hospital / LTC Providers


Reducing Hospital Admissions
@Terry Vine, Getty Images

The Long-Term Quality Alliance (LTQA) issued a white paper dealing with preventable hospitalizations. Thirty-day readmissions to hospitals are a big issue and soon providers will be “dinged” financially for unnecessary hospitalizations. LTQA wants to set a framework to better define and then address hospitalizations. Here are the action steps they outline:

  1. Define the domain as potentially preventable hospitalizations, as opposed to potentially preventable hospitalizations from a particular setting or potentially preventable readmissions within a particular time period.

  2. Define as precisely as possible the population of frail and chronically ill adults and older people who are receiving long-term services and supports.

  3. Begin a process to develop appropriate measures or measure-based procedures to identify potentially preventable hospitalizations in the LTQA population.

  4. Advocate with researchers and funders for rigorous studies to test the validity of existing and new measures of potentially preventable hospitalizations for frail and chronically ill adults and older people who are receiving long-term services and supports.

  5. Monitor and advocate with CMS the positive and negative effects on frail and chronically ill adults and older people of programs intended to reduce potentially preventable hospitalizations.

  6. Identify ways to help clinicians who make decisions about hospitalizations for frail and chronically ill adults and older people in various settings understand current and new programs intended to reduce potentially preventable hospitalizations, the rationales for these programs and the measures that are or will be used to evaluate their effectiveness.

It is not surprising that potentially preventable hospitalizations are three times more common among hospitalizations paid for by Medicare than among hospitalizations paid for by Medicaid or private insurance. A survey of Medicare revealed that people with chronic illness are seven times more likely than those with no chronic illnesses to have a potentially preventable hospitalization, and those with four or more chronic illnesses were 99 times more likely to have such a hospitalization!

One doesn’t have to look far at the conditions that could contribute. Just review the main MDS categories.

Practices Studied

A 6-month quality improvement pilot project conducted in three Georgia nursing homes in 2007 used a set of procedures and tools intended to reduce potentially preventable hospitalizations. In each facility, a staff team was designated to participate in training sessions, and one team member was appointed as the project champion to lead the team and promote the use of the project procedures and tools. Every two weeks, the project champion completed a review form on any hospitalizations that occurred, noting what happened and whether anything could have been done to avoid the hospitalization. The 6-month pilot project resulted in a 50% reduction in hospitalization rates across the three facilities compared with rates during the 15 months before the project began.

Observation from Researchers

The use of such review forms could be a powerful learning strategy in future quality improvement initiatives focused on reducing avoidable hospitalizations.

Case 2

A second 6-month quality improvement project conducted in 25 nursing homes in three states in 2009 used a revised set of procedures and tools intended to reduce potentially preventable hospitalizations. One nursing home staff member, usually a nurse, was appointed to be the project champion and to complete a structured review of any hospitalizations that did occur, what happened, and whether anything could have been done to avoid the hospitalization.

This 6-month project resulted in a 17% reduction in hospitalizations from the 25 nursing homes, with a higher reduction (24%) in the 17 nursing homes that were most engaged in the project.

Narrative reports of collaborative calls with the project champions indicated that some of them “change(d) their perceptions of avoidability of (hospital) transfers” and “initiated dialogue with other staff about the potential for preventing or anticipating events that could lead up to a hospital transfer.”

Observation from Researchers

The researchers noted that additional studies wee needed to understand the factors associated with changes in staff perceptions and behaviors. From what was published, it would seem more open communication among staff and from staff to the medical director would foster frank discussions about needed hospitalizations.

Case 3

A third project conducted in a hospital-based skilled nursing unit used several approaches to reduce hospital readmissions from the unit.

One of the approaches was multidisciplinary meetings, referred to as Team Improvement for the Patient and Safety (TIPS) meetings. Nurses, nursing aides, physicians, therapists, social workers, a nursing home administrator, and other staff members attended the TIPS meetings, which were intended to examine the “root causes” of particular hospital readmissions and identify ways in which they might have been avoided.

The meetings usually lasted 30 minutes, and meeting times were varied to ensure that night and evening staff were included. Nursing aides were paid to attend TIPS conferences after their shifts ended, and a ‘lessons learned” email was sent to all direct care staff after each meeting.

A pre-post evaluation indicated that hospital readmissions from the unit dropped by 20% during the project period.

Observation from Researchers

The researchers who conducted these three studies point out that it is not clear which component(s) of the interventions resulted in the reduction in hospitalizations and that the retrospective reviews by facility staff can be time-consuming. On the other hand, the interventions did result in large reductions in hospitalizations.

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