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Preventing Short-Stay Readmissions

Preventing Short-Stay Readmissions

Every care transition carries increased risk of adverse events, poor health outcomes, emotional instability, and high healthcare costs—and the risks are even more elevated for older adults, especially for those with multiple chronic conditions. 

Although research has mainly focused on transitions from hospital to home or skilled-nursing facility (SNF), a few studies have highlighted the need for increased attention on short-stay patients. A Department of Health and Human Services' Office of Inspector General report found that 22% of Medicare beneficiaries who had spent 35 days or less in a SNF for rehabilitation after hospital discharge experienced an adverse event. Fifty-nine percent of the adverse events were deemed preventable by physician reviewers and 79% resulted in prolonged SNF stay, transfer to a different SNF or postacute facility, or hospitalization. Problems related to medication and patient care accounted for most of these adverse events, followed by infection-related events. (OIG) Another study found that fewer than 53% of short-stay patients at SNFs have a successful—meaning no hospitalizations or deaths within 31 days—discharge home or to community-based services (Guzik and Kothari). 

​​​Reducing hospital readmissions has long been an area of focus as they are associated with a quadrupled mortality rate within 100 days (Burke et al "Hospital"). Although national initiatives such as the SNF Value-Based Purchasing program aim to incentivize facilities in improving postacute and transitional care services, monetary penalties or incentives only go so far without providing SNFs the tools and resources needed to make such improvements. In fact, the program did not offer a viable path for nearly all (99.3%) low-performing SNFs to avoid financial penalties through improved readmission rates (Burke et al. "Skilled"). These results suggest that postacute care providers need actionable improvement guidance that hinges on current best practices. 

Short-Stay Resident Needs 

​​​Compared with long-term residents, short-stay patients generally have higher acuity and are often recuperating from a hospital stay for an acute condition, such as a stroke or procedure. Despite their higher acuity, they also tend to need more use of clinical equipment, ancillary postacute or subacute services, and care coordination with specialty providers, possibly including transportation. Thus, short-stay patients may need closer monitoring, quicker recognition of problems, and earlier intervention to avoid hospital readmissions or emergency department visits. 

Short-stay patients also may have quite different expectations regarding their health status and trajectory than long-term residents. As little as a few days before their admission to the aging services organization, short-stay patients may have been at home, not expecting to shortly be in an SNF. They may be unfamiliar with aging services settings, and they may have unrealistic ideas about their condition and rehabilitation goals. Short-stay patients who are younger than the long-term care population may have unrealistic expectations and be uncomfortable in aging services settings, especially when asked to room with an older resident or patient. 

These unrealistic expectations can pose safety risks. Short-stay patients may have poor safety awareness, want to prove they can be independent, or be uncomfortable accepting help with activities of daily living such as transfers, ambulation, and toileting. As a result, they may engage in unsafe behaviors. They may also feel like they are receiving mixed signals if, for example, rehabilitation therapy tells them they will go home as soon as they are independent with transfers and ambulation, but nursing instructs them to always use the call bell. (ECRI "Subacute") 

Purposeful Rounding 

​​Purposeful or hourly rounding is an evidence-based approach to proactively meet patient needs in a timely, scheduled manner, which is a cornerstone of person-centered care. Purposeful rounding has shown to improve provider-patient communication, call light/bell usage, pain management, fall prevention, pressure injury rates, and patient satisfaction (Daniels; Mitchell et al.). 

​An early study of hourly rounding used the following actions during rounds to improve patient safety in nursing units (Meade et al.): 

  • Assess patient pain levels using a pain-assessment scale (if staff other than registered nurses [RNs] are doing the rounding and the patient is in pain, contact an RN immediately, so the patient does not have to use the call light for pain medication) 
  • Add "medication as needed" to RN's scheduled list of things to do for patients and offer the dose when due 
  • Offer toileting assistance 
  • Assess the patient's position and comfort and ask if patient needs to be repositioned and is comfortable 
  • Make sure the call light is within the patient's reach 
  • Place the telephone within the patient's reach 
  • Place the TV remote control and bed light switch within the patient's reach 
  • Place the bedside table next to the bed 
  • Place the Kleenex box and water within the patient's reach 
  • Place the garbage can next to the bed 
  • Prior to leaving the room, ask, "Is there anything I can do for you before I leave? I have time while I am here in the room. 
  • Tell the patient that a member of the nursing staff (use names on white board) will be back in the room in an hour (or two hours if two-hour protocol is in use) to round again 

Fall Prevention​ 

One of the main goals of purposeful rounding—aside from increased monitoring—is fall prevention. Purposeful rounding includes conducting environmental hazard checks within the patient's room, such as ensuring frequently used items are within arm's reach of the patient and helping with any ambulation. As falls remain the highest claim against aging services organizations and is one of the leading events that trigger care transitions, fall prevention remains paramount to an organization's patient safety program (CNA; Joseph et al.). 

​​Aging services organizations should appoint or solicit members for a falls team of champions in front-line staff to bridge education and best practices from the fall reduction program to the purposeful rounding program to optimize efforts. These individuals can track baseline fall events, help train staff, suggest process and quality improvements, and report results to leadership as well. 

Change in Condition 

Another benefit of hourly rounding is providing more opportunities for front-line staff to recognize changes in patient condition. The patient's baseline status should be established and documented upon admission, typically through new admission risk assessments and initial comprehensive nursing assessments. Such assessments include vitals, mobility and physical health, and cognition and mental health. Establishing baselines is critical to facilitating prompt early detection of changes in condition, which often consist of the following (AHRQ): 

Physical changes: 

  • Walking 
  • Urination and bowel patterns 
  • Skin 
  • Level of weakness 
  • Falls 
  • Vital signs 

Nonphysical changes: 

  • Demeanor 
  • Appetite 
  • Sleeping 
  • Speech 
  • Confusion or agitation 
  • Resident complaints of pain 


  • Understand which resident populations are at greatest risk of readmission 
    • Target residents with limited English proficiency 
  • Effectively staff nurses during resident care (e.g., decrease reliance on overtime, optimize nurse-resident ratios) 
  • Implement comprehensive discharge planning 
    • Clearly communicate postdischarge instructions 
    • Include medication use, activity level, and symptoms to report 
    • Use language-assistance services as appropriate 
    • Involve caregivers and family members 
    • Use teach-back method to ensure resident and family understanding 
  • Ensure residents schedule a seven-day discharge follow-up appointment 
  • Implement a robust home healthcare program 

Learn how ECRI can help you address the increasingly complex aging services care delivery and regulatory environment.