More than ever, hospital readmissions are proving to be detrimental to the overall health of the resident (with transfers back and forth) and now disadvantageous to the transferring facility’s overall quality score. Many facilities do not have a solid program/process in place to manage and avoid these transfers which puts them at risk.

Facilities and organizations are struggling to improve and/or implement their process to address hospital readmissions.  I had the opportunity to work with an organization that for more than a decade has successfully managed their hospital readmissions, and I am happy to share best practices in this posting.

Best Practices for Managing Hospital Readmissions

Successful processes/programs begin with a whole facility approach; each staff member having a part in managing the residents’ care beginning with the initial admission.  The entire Intake (Admissions) team is crucial to ensuring successful outcomes for the residents.

It all begins with admissions.

Admission staff meets and builds rapport with not only the resident but also the family.  They discuss the facility process for maintaining and providing all care needed at the facility – thus avoiding transfers that can undermine their loved ones overall health.  The Admission Team introduces the resident and family to the Nursing staff, not only the nurse checking in the resident and the nurse assistant but the Management Team: Administrator, Director of Nursing (DON), Assistant Director (ADON) or Nurse Manager/ Supervisor, and if possible the Nurse Practitioner and Social Worker. The meetings are brief but the message is the same, “Welcome! We appreciate the opportunity to aid your loved one on the road to recovery/ or provide care for your________.”  All staff members convey a sense of calm, smiling with sincerity and kindness. Caregivers are building the trust that the family and resident are seeking.

Each staff member wears clearly visible, easy to read name badges that list their name and position in large print. Remember, most people struggle to remember people’s names even when not dealing with recovery or an ill family member.  Make it easy for them to recognize the care givers. Families and responsible parties are provided with a list of caregivers and their contact information.  The resident and/or family are reassured that not only can they reach you by seeing you at the facility but they can also reach you by phone and/or email (where possible).

Develop trust with continuing administrator visits.

Each day for the next 3-7 days the DON/ADON or designee should visit the new resident (the Administrator can also complete this) reintroducing themselves by name and title, taking the residents hand in theirs, further building the bond while subtlety assessing cognitive status, strength of the residents grip and skin temperature as well as assessing general satisfaction while asking them open ended questions as to their stay thus far. The visits can then be extended, letting the resident know you will be back to visit soon - again building that feeling of inclusion and caring.  When you build a successful bond the families are less likely to demand you send their loved one back to the hospital at the drop of a hat, they will listen to you as you state that you can provide the services necessary in-house while decreasing the traumatic effects on their loved one from the transfer experience. They will learn to trust your calmness, experience and advice. They will recognize that you have the resident’s best interest in mind.

Have a gatekeeper process in place.

In addition to building a bond and hopefully the trust of your resident/family members, you need to have a Gatekeeper process in place.  

If your facility doesn’t already have one, it’s time to create one and any portion to begin with is better than nothing.  This process is far from easy; it takes a lot of education, follow-through and buy-in from not only your staff but the residents and family.  Education, communication, rapport and a sense of security/trust are all required for this process to be successful.  It begins with preadmission/admission building a rapport and sense of security/trust with the family and resident. In Elements Of An Effective Gatekeeper Program Part 2 (coming soon), I discuss the gatekeeper process post-admission and explore a best practice approach for avoiding hospital readmissions – involving all staff.