The consequences of lack of communication between hospitals and skilled nursing facilities (SNFs) are not new knowledge. According to a 2013 study, in the U.S. alone, more than 5 million patients transition from hospital to SNFs yearly. These transitions heavily rely on the thorough communication of healthcare professionals and paraprofessionals to ensure adequate care for patients. However, hospitals and local SNFs typically operate as separate entities causing a myriad of miscommunication. Communication issues that may happen between the facilities include incomplete, contradicting and/or mismatching verbal and written care plans. These problems may cause SNF staff to delay—or never deliver—proper care for patients, resulting in potentially fatal consequences. For example, noting the wrong medication can cause a stroke patient to relapse into another stroke and an avoidable hospital readmission. While many factors can be used as scapegoats to explain these mistakes, these problems are not new, and as professionals in the field, SNFs should establish better communication and points of accountability before accepting a patient to ensure the dignity and quality of care of patients. A recent study published by the Journal of the American Geriatrics Society by multiple medical doctors have indicated that a significant number of hospital readmissions from SNFs were likely preventable.
Previous studies on potentially avoidable readmissions (PARs) used measures focused on SNF data and perspectives. However, this study presents the first review of PARs from the detailed perspectives of both the SNFs and hospital. As such, this report provides a rigorous review of the inadequacies in the self-assessments of hospitals and SNFs regarding whether a hospital readmission was avoidable or not, and offers suggested improvements in future readmission assessments.
Its findings conclude there is a substantial discrepancy between what hospitalists deem as avoidable readmissions and what SNFs consider as avoidable ones: Hospital physicians tend to consider hospital readmissions more as preventable (N=36 of 120, 30.0%), compared to the perspectives of SNF staff (N=16, 13.3%). This study argues that this difference is due to the limited communication between the two facilities and the lack of extensive advanced care planning within each of the facilities.
In the study, hospitalists account insufficient medical care during the initial admission of patients as the greatest factor for avoidable hospital readmission. This could prove problematic as patients discharged back home, to SNFs or assisted living facilities can quickly return to the hospitals, incurring potentially exorbitant costs and reduced quality of life.
SNF results, on the other hand, note that that it is due to poor management of existing SNF resources as the main reason for avoidable hospital readmissions. Improper or inefficient use of existing SNF resources could include poor staffing to patients, medication mismanagement, neglect and other elder mistreatment found in SNFs. The second highest rated factor that SNF staff mentioned to contribute to readmissions is the poor communication between the SNF and hospital, including the emergency department and outpatient clinics. It is the healthcare professionals’ responsibility, however, to ensure the proper care plan is made known and the next team of healthcare providers learn the patients’ medical condition so rehospitalizations do not occur.
This research study, however, did indicate some limitations to their results as only one academic hospital was reviewed compared to its 23 SNFs surveyed. Thus, conclusions cannot be applied to all hospitals across the nation. Nevertheless, the study does provide valuable ideas that can help advance healthcare policy and improve interactions between hospital and SNFs ultimately to lower our healthcare cost and rehospitalization rate.
If you or a loved one has been rehospitalized due to improper medical treatment from a long-term-care facility, such as one in Fullerton or Irvine, California, contact the Law Offices of Ben Yeroushalmi immediately.