Understanding Hospital Re-Admissions: Causes and Consequences for Nursing Homes

Hospital re-admissions are a critical concern for nursing homes, impacting both resident outcomes and the facility’s financial and regulatory standing. For nursing home administrators and staff, reducing unnecessary re-admissions is not just a goal—it’s a necessity to maintain compliance, improve care quality, and enhance resident well-being.

What Are Hospital Re-Admissions and Why Do They Matter?

A hospital re-admission occurs when a resident is discharged from a nursing home to a hospital and then readmitted within a short period, typically within 30 days. These re-admissions can result from various medical, logistical, and systemic factors.

From a quality standpoint, frequent re-admissions indicate potential gaps in care. Facilities with high re-admission rates may face financial penalties, lower CMS ratings, and decreased trust from families and referral sources. Nursing Home Consultants like Qsource work with healthcare providers to develop strategies that minimize unnecessary hospitalizations and improve care coordination.

Common Causes of Hospital Re-Admissions in Nursing Homes

Hospital re-admissions are often triggered by a combination of clinical conditions, inadequate care planning, and system-level failures. Understanding these causes is the first step in developing prevention strategies.

• Many re-admissions stem from preventable infections. Poor hygiene, dehydration, and inadequate monitoring of early symptoms contribute to this issue.
• Implementing strict infection control protocols and monitoring residents for early signs of infection can reduce hospitalization risks.

• Falls are one of the most common causes of hospitalization among elderly residents. Contributing factors include medication side effects, muscle weakness, environmental hazards, and cognitive decline.
• Nursing homes can mitigate fall risks through fall prevention programs, mobility assessments, and environmental modifications.

• Polypharmacy and improper medication administration can lead to severe side effects, requiring hospitalization.
• Nursing homes can prevent medication-related re-admissions by partnering with pharmacy consultants, conducting regular medication reviews, and ensuring adherence to Qsource's medication safety initiatives.

• Heart failure, chronic obstructive pulmonary disease (COPD), and diabetes are common chronic conditions in nursing homes that, when poorly managed, lead to emergency hospital visits.
• Proactive care plans, routine monitoring, and coordinating with healthcare quality experts like Qsource help ensure residents receive timely interventions before conditions worsen.

• A lack of clear discharge instructions, inadequate follow-up, and ineffective communication between nursing homes and hospitals often lead to re-admissions.
• Nursing homes should establish strong transition-of-care protocols, ensuring residents and their families understand post-discharge care expectations.

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The Consequences of High Re-Admission Rates

Nursing homes with high re-admission rates face multiple consequences, ranging from regulatory penalties to reputational damage.

• Medicare’s Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program penalizes facilities with high re-admission rates, reducing their reimbursement rates.
• Private insurers may also decline to cover repeated hospitalizations, leading to increased financial strain on nursing homes.

• CMS tracks hospital re-admissions as part of its Five-Star Quality Rating System.
• A high re-admission rate negatively impacts the Quality Measures domain, leading to a lower overall facility rating.
• Facilities with consistently poor ratings may face heightened regulatory oversight and reduced referrals.

• Frequent hospitalizations disrupt residents' stability, increasing their risk of complications such as delirium, infections, and functional decline.
• Many elderly residents experience hospital-associated deconditioning, making their return to a nursing home setting even more challenging.

• Families evaluating long-term care options consider hospital re-admission rates when choosing a facility.
• Healthcare networks and hospitals may be hesitant to refer patients to nursing homes with high re-admission numbers, impacting census and financial stability. 

How Nursing Homes Can Reduce Re-Admissions

Reducing re-admissions requires a multi-faceted approach that includes proactive medical care, staff education, resident engagement, and strategic partnerships.

• • Train staff to identify early signs of infection.
  • Implement antibiotic stewardship programs to prevent unnecessary antibiotic use and resistance.

• • Utilize Qsource's medication reconciliation programs to ensure proper medication use.
  • Conduct pharmacist-led reviews of high-risk medications.

• • Conduct routine fall risk assessments.
  • Use assistive devices and encourage safe mobility practices.

• • Implement early intervention programs for CHF, COPD, and diabetes.
  • Use telehealth consultations for remote monitoring and follow-ups.

• • Provide clear, written discharge instructions to residents and families.
  • Establish post-discharge follow-up calls to monitor recovery and prevent complications.

• • Qsource offers quality improvement initiatives that help nursing homes track and reduce hospital re-admissions.
  • They provide educational resources, clinical tools, and data-driven strategies tailored for skilled nursing facilities.

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 Hospital re-admissions are a pressing issue for nursing homes, affecting resident health, financial stability, and regulatory compliance. By addressing common causes such as infections, falls, medication errors, and poor discharge planning, nursing homes can significantly lower their re-admission rates while improving quality of care.

Partnering with organizations like Qsource provides invaluable guidance and resources to help facilities implement effective re-admission reduction strategies. Nursing home administrators and staff must take a proactive approach, ensuring that every aspect of care—from infection control to medication safety—supports resident well-being and long-term facility success.