An Organizational Strategy to
Prevent Hospitalizations
Mary J. Dyck, PhD, RN, LNHA
MyoungJin Kim, PhD
Susan Hovey, MSN, RN
Readmission 2014
1
Purpose
• Determine if there is a significant difference in
readmission rates from SNFs to hospitals with
the implementation of a day long skills lab
training program for SNF nurses
Readmission 2014
2
Review of Literature
• The Affordable Care Act established a Hospital
Readmission Reduction Program
• Center for Medicare and Medicaid Services
(CMS) must reduce payments to hospitals with
excess readmissions
• Started 10/1/2012
– (CMS, n.d.)
Readmission 2014
3
Review of Literature
• Included readmissions for AMI, HF, and
pneumonia.
• Penalties to hospitals with excess
readmissions for patients discharged with
these three diagnoses include
– a 1% reduction of total Medicare billings in 2013,
– 2% reduction of total Medicare billings in 2014,
– 3% reduction of total Medicare billings in 2015
• (Zigmond, 2012)
Readmission 2014
4
Review of Literature
• all-cause readmission
– within 30 days of discharge
– the patient does not have to be readmitted for the
same condition or related conditions to be
included.
• This policy has driven hospitals to find ways to
decrease their readmission rates.
Readmission 2014
5
Review of Literature
• In 2006, one-fourth of Medicare beneficiaries
discharged from a hospital to SNF were
readmitted within thirty days costing
Medicare 4.34 billion dollars
– (Berkowitz et al., 2011; Boxer et al., 2012; Mor, Intrator, Feng, &
Grabowski, 2010)
• In Illinois, readmissions from SNF in 2006 were
24 – 26.9%
– (CMS, n.d.)
Readmission 2014
6
Review of Literature
• Currently, the only penalty to SNF with an
excess of readmissions is a loss in revenue due
to a decrease in referrals
• SNF providers are sure that a similar penalty
structure is inevitable in the future
– (Zigmond, 2012)
Readmission 2014
7
Review of Literature
• The American Health Care Association (AHCA)
Quality Initiative is to reduce the number of
hospital readmissions within 30 days from SNF
by 15% by March 2015
– (American Health Care Association [AHCA] website, n.d.)
Readmission 2014
8
Review of Literature
Strategies to Reduce Readmissions Rates from SNF to Hospitals
• Standardizing physician
admission procedures
• Follow-up phone calls
within 48 hours of discharge
– (Berkowitz et al., 2011)
– (Jacobs, 2011)
• Heart failure staff education
programs for SNF nurses
• Partnerships between acute
and post-acute providers
– (Boxer et al., 2012)
Readmission 2014
– (Aston, 2011).
9
Research Questions
• Is there a difference in readmission rates after
a one day skills lab implementation for nurses
employed in SNF 3 months, 6 months, and 9
months after training
Readmission 2014
10
Sample
• Used secondary data collected and deidentified by a senior care corporation in
Illinois
• Staff from each facility collected data on
hospital readmissions and it was aggregated
by the senior care corporation
• 32 SNF owned and operated by the senior
care corporation.
Readmission 2014
11
Sample
• Data included
– By facility by month
• Admissions (New admissions to the facility and admissions to the
hospital by current residents)
• all cause readmissions within 30 days
• Number of nurses employed and the number of nurses
that completed skills lab training
– Approved by the Illinois State University Institutional Review
Board before data was analyzed and a Data Use agreement
was signed by the senior care corporation
Readmission 2014
12
Procedure
• The senior care corporation
implemented a full day skills
lab in September 2011
• Training consisted
– Revised January 2012
• 2012 all training was done
at the simulation lab at
Illinois State University
• A nurse with a Master’s of
Science degree in Nursing
(MSN) conducted the
training
– Hour lecture CHF
– Hour lecture COPD
– 45 minutes of practice on
breath sounds with
simulation manikin
– 3 hours discussion and
practice on acute changes in
patient condition
– 1.5 hour scenarios with SBAR
and calling physician
*February 2013 50% of nurses from 12 of 32 facilities
Readmission 2014
13
Methodologies
• Data were analyzed using Statistical Package
for the Social Sciences (SPSS) 20
• Data were assessed for outliers
• Assumptions were checked prior to data
analysis.
• Mann-Whitney test
• All statistical significance were reported
at p ≤ .0167 using Bonferroni's adjustment for
Type I error due to multiple tests
Readmission 2014
14
Results
May 2013
Aug 2013
Nov 2013
N*
Mdn(IQR)
U
Df
z
p
Training ≥ 50%
12
1.00(1.00)
90
31
-1.22
.255
Training ≤ 50%
20
.00(2.75)
Training ≥ 50%
12
2.00(1.75)
95
31
-1.01
.346
Training ≤ 50%
20
1.00(2.75)
Training ≥ 50%
12
1.50(2.00)
95.5
31
-1.04
.346
Training ≤ 50%
20
1.00(2.00)
No significant difference found
Readmission 2014
15
Discussion
• Hospital readmission rates did not change
significantly for SNF who had 50% or more of
their nurses complete the skills lab training 3
months, 6 months, and 9 months after
training
Readmission 2014
16
Discussion
• When you look at the descriptive statistics,
SNF with 50% or more of their nurses
completing training had a slightly higher
median of readmissions for each month in
comparison to the total and SNF with less
than 50%
• Why?
Readmission 2014
17
Discussion
• Improved assessment skills
• Increased awareness on identifying changes in
condition
• Skilled at using the SBAR and notifying
physicians
• Evolving skills lab
Readmission 2014
18
Limitations
• Only one senior care
corporation may not be
representative of SNF in
general.
• The senior care corporation
collected the data so the
study is relying on the
accuracy of their data
collection techniques.
• Nurse staffing is constantly
changing so data may have
not accurately captured
nurses actually trained
• Cannot capture training of
nurses outside of the
simulation lab
• The sample size was small
Readmission 2014
19
Future Research
• Currently, research in this area is limited so
the need is great
• How many days following discharge residents
are generally readmitted
• The reasons that residents from SNF are
readmitted following discharge from the
hospital
Readmission 2014
20
Future Research
• Readmission rates for residents recently
admitted to SNF vs. residents who were
hospitalized from the SNF to the hospital
Readmission 2014
21
Conclusion
• This is a hot topic
– Interest from federal and state government
– Interest from healthcare corporations
– Studies can ultimately impact
• Patient outcomes
• Reduce costs of healthcare
• Improve reimbursement
– Relevant to today’s healthcare
Readmission 2014
22
References
•
•
•
•
•
•
•
•
•
American Health Care Association website (n.d.). Retrieved from
http://www.ahcancal.org/quality_improvement/qualityinitiative/Pages/TheGoals.aspx#1
Aston, G. (2011). Long-term care: Your new priority. H&HN: Hospitals & Health Networks,
85(4), 30-32.
Berkowitz, R., E., Jones, R., N., Rieder, R., Bryan, M., Schreiber, R., Verney, S., &Paasche-Orlow, M. (2011).Improving
disposition outcomes for patients in a geriatric skilled nursing facility. Journal of the American Geriatrics
Society, 59(6), 1130-1136. doi: http://dx.doi.org/10.1111/j.1532-5415.2011.03417.x
Boxer, R., S., Dolansky, M., A., Frantz, M., A., Prosser, R., Hitch, J., A., & Piña, I., L. (2012).The bridge project:
Improving heart failure care in skilled nursing facilities.Journal of the American Medical Directors
Association, 13(1), 83.e1-7.doi: http://dx.doi.org/10.1016/j.jamda.2011.01.005
Centers for Medicare and Medicaid Services [CMS] (n.d.).Readmissions reduction program. Retrieved
from http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/AcuteInpatientPPS/Readmissions-Reduction-Program.html
Jacobs, B. (2011). Reducing heart failure hospital readmissions from skilled nursing facilities. Professional Case
Management, 16(1), 18-26. doi: http://dx.doi.org/10.1097/NCM.0b013e3181f3f684
Medicare Hospital Quality Chartbook, (2012).Performance report on outcome measures.
Retrieved from
http://cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/Downloads/MedicareHospitalQualityChartbook2012.pdf
Mor, V., Intrator, O., Feng, Z., & Grabowski, D. C. (2010).The revolving door of rehospitalization from skilled nursing
facilities. Health Affairs, 29(1), 57-64. doi: http://dx.doi.org/10.1377/hlthaff.2009.0629
Zigmond, J. (2012). Avoiding the penalty box. Modern Healthcare, 42(5), 38-39.
Readmission 2014
23