Too many people make the dangerous roundtrip from hospital to nursing facility and back again. These transfers may increase risks of delirium, medication errors, falls, and infection. There is no doubt that some patients die as a result of these transfers. And, they cost payers—Medicare, Medicaid, and private insurance—hundreds of millions of dollars each year.

The real tragedy: By some estimates as many as 60 percent of these rehospitalizations are preventable. 

Now, nursing facilities and their partner hospitals are taking steps to cut these readmissions. In researching a new article for the journal Health Progress, published by the Catholic Health Assn., I had the chance to visit and talk to some of the nation’s most creative senior service providers. And I learned about both the challenge of reducing hospital readmissions and some cutting-edge solutions.

Some of these initiatives are being driven by new Medicare rules. Among them: On Oct 1, Medicare will begin cutting  payments to hospitals where too many patients are readmitted within 30 days of discharge. While the initial penalties are relatively modest and for only three conditions—heart failure, pneumonia, and heart attacks—they will gradually stiffen. And the new rules seem to have changed the mindset of many hospital administrators.

Increasingly, hospitals are improving discharges and keeping a close eye on patients after they leave. No longer do they abandon their patients once they roll out the front door. Many are putting transition programs in place—often using care managers, social workers, or nurses—to assist patients who are discharged to home. And slowly, they are beginning to work more closely with nursing facilities—both skilled nursing and long-stay nursing homes—to reduce readmissions.

At the same time, the best nursing facilities are making big changes of their own. They include:

  • Increasing staff and improving training for nurses and aides to help them identify and treat situations that can lead to hospitalizations.  At Wheaton-Franciscan Healthcare in Wisconsin, nursing facility aides are trained to identify warning signs in heart failure patients and how to communicate what they see to staff nurses. These steps often prevent a crisis before it occurs.    
  • Working with primary care doctors to encourage them to allow the nursing facility to treat many acute episodes rather than ordering patients back to the hospital.
  • Asking patients, residents, and their families whether they want to be hospitalized. When Hebrew Senior Life asked patients at its post-acute care nursing facility in Boston what they wanted, it discovered many preferred to stay where they were. Now, the HSL system is expanding this program to residents of its long-stay nursing home.

Steps such as these are especially important since more patients are receiving post-acute and post-surgical care in skilled nursing facilities rather than in hospitals themselves.

It is important to keep in mind that reducing hospitalizations is not the goal: The real aim is improving the quality of care for these patients, many of whom need both medical care and personal assistance. Sometimes, they should be hospitalized. But often, they can receive the best care by staying where they are.

The medical and long-term care systems have a long way to go in their efforts to improve care for the frail elderly and others with severe chronic disease. But finally they are beginning to take some big steps down that road.