Home Care Heroes Blog

Taking Responsibility for Reductions in Hospital Readmissions: Be Careful!

Elizabeth E. Hogue, Esq. has written an in-depth article, "Taking Responsibility for Reductions in Hospital Readmissions: Be Careful!" that we encourage you to read, reposted here:

Ankota home care software

Hospital administrators are increasingly focused on decreasing readmission as they continue to receive penalties in the form of reductions in reimbursement from the Medicare Program. Hospital staff appropriately seek assistance from post-acute providers in order to achieve reductions. There is no doubt that Medicare-certified home health agencies, HME suppliers, private duty home care agencies, hospices, skilled nursing facilities (SNFs), assisted living facilities (ALFs), outpatient therapists, etc. can assist hospitals to reduce readmissions. The post-acute industry generally welcomes the recognition that it has a crucial role to play in this regard.

BUT, BE CAREFUL! It appears that staff at some hospitals have only a superficial understanding of how reductions can be achieved. This is true, in part, because there is a general lack of evidence and data to show what activities contribute to reductions in readmissions. It remains unclear whether hospital discharge planning activities, for example, can have a substantial impact on reductions in readmissions.

There is a tendency on the part of hospitals, however, to put the entire responsibility for reductions on the shoulders of post-acute providers. This point of view may lead to some potentially harmful results, including failure to reduce readmissions. It may also support the argument that hospitals should be able to choose post-acute providers for patients since they suffer the financial consequences when patients are readmitted.

On the contrary, it seems likely that reductions in readmissions will be achieved only through partnerships between hospitals and post-acute providers of all kinds. The operative word is clearly "partnership." This point of view is supported by Conditions of Participation (CoPs) of the Medicare Program for hospitals that govern discharge planning. Specifically, discharge planners/case managers at hospitals are required to:

  • Screen all inpatients soon after admission to determine which ones are at risk of adverse health consequences post-discharge if they lack discharge planning. Screening must include consideration of the following factors:

o Patients' functional status and cognitive ability

o Type(s) of post-hospital care that patients require, such as:

  • Home Health, attendant care, and other community-based services
  • Hospice or palliative care
  • Respiratory therapy
  • Rehabilitation services (PT, OT, Speech, etc.)
  • End Stage Renal Dialysis services
  • Pharmaceuticals and related supplies
  • Nutritional consultation/supplemental diets
  • SNFs
  • ALFs
  • Medical equipment and related supplies
  • Home and physical environment modifications
  • Transportation services
  • Meal services
  • Household services, such as housekeeping, shopping, etc.

o Whether the type(s) of post-hospital care require(s) the services of health care professionals or facilities

o Availability of required post-hospital health care services to patients

o Availability and capability of family and/or friends to provide follow-up care in the home

  • Evaluate post-discharge needs of inpatients identified in the first stage, or of inpatients who request an evaluation, or whose physician requests one. Evaluations must include the ability of patients to self-care post-discharge. An evaluation of the ability to self-care requires hospitals to actively solicit information regarding this issue not only from patients or their representatives, but also from family, friends, and support persons.
  • Develop a discharge plan, if indicated by the evaluation or at the request of the patient's physician
  • Initiate implementation of the discharge plan prior to the discharge of inpatients. This requirement includes provision of inpatient education/training to patients for self-care, or to patients' families or other support persons who will provide care in patients' homes. It includes arrangements for: 

o Transfer to rehabilitation hospitals, long term care hospitals, or long term care facilities 

o Referrals to home health agencies or hospices

o Referrals for follow-up with physicians and therapists

o Referrals to pertinent community resources that may assist with financial, transportation, meal preparation or other post-discharge needs

Anecdotally, it appears that hospital discharge planners/case managers are not consistently engaging in these activities and others required by the CoPs. Compliance with the CoPs for discharge planning may have a significant impact on reductions in readmissions in partnership with post-acute providers of all types.

©2015 Elizabeth E. Hogue, Esq.  All rights reserved.  No portion of this material may be reproduced in any form without the advance written permission of the author.

If you'd like to learn more about Ankota's software for home care and care transitions, click here for a demo or click the following link to download our latest white paper,  "Why Care Transitions is the Next Big Thing for the Home Care Industry."


Ankota provides software to improve the delivery of care outside the hospital, focusing on efficiency and care coordination. Ankota's primary focus is on Care Transitions for Readmission avoidance and on management of Private Duty non-medical home care. To learn more, please visit www.ankota.com or contact Ankota.


Your Comments :

Read more of what you like.