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Cheryl Boldt, RN, LNHA

When Medicare beneficiaries have an unfortunate event or illness that leads to hospitalization, they can find themselves in a whirlwind of activity, decision making and adjustment. The clock starts ticking and the risk for readmission to the hospital begins on the day a Medicare A patient qualifies for and is transferred to a Skilled Nursing Facility (SNF). Hospitals are held responsible to prevent acute setting readmissions and it is expected that SNF Teams have systems in place to prevent those returns. Patients count on all of us to minimize the need for them to go back to the hospital.

Hospitals are focused on improving readmission rates because their reimbursement is on the line. In fiscal year 2013, hospitals started facing penalties for high readmission rates under the Hospital Readmissions Reduction Program. Initial performance evaluations will be based upon the 30-day readmission measures for heart attack, heart failure and pneumonia that are currently part of the Medicare pay-for-reporting program and reported on Hospital Compare.

Many readmissions to the hospital are avoidable, thus it is imperative that a Skilled Nursing Facility implements proactive strategies to prevent hospital returns. This session will include an overview of these strategies related to the admission process, teaming and communication within and between shifts and departments, support services, advanced disease management protocol tools, provider collaboration and post-transition follow-up.

Preventing hospital readmissions is a win for everyone and the right outcome for the patient, SNF provider and the hospital. Join us to discuss what needs to be done to wipe out preventable readmissions to the hospital and solidify your position as the Skilled Nursing Facility provider of choice.


At the completion of this session, the attendees will be able to:
  1. Use the Hospital Compare website to monitor return to hospital data for your referring hospital(s)
  2. Implement 3 admission process strategies key to minimizing the risk for re-hospitalization
  3. Utilize 3 effective teaming/communication systems between shifts and departments that contribute to early identification and intervention to prevent a readmission to the hospital
  4. Identify the types of support services your facility needs for efficient, timely and effective clinical intervention
  5. Formally collaborate with strategic health partners to assure safe transitions between locations that will minimize return to the acute setting
  6. Customize post-transition follow-up
This session includes a PowerPoint presentation, handouts, group discussion, humor and personal/professional action planning. It is ideally 4.5 to 6 hours in length, but can be customized into 3 sessions lasting 1.5 to 2 hours each to run concurrently at a conference or as a whole day session.

The targeted audience includes CEOs, CFOs, Administrators, Directors of Nursing, Medical Directors, RN Assessment Coordinators and Case Managers, all team members in any discipline in a skilled nursing facility and all consultants or corporate support staff of SNF post-acute care services.

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