2015 marks the year when the Centers for Medicare & Medicaid Services (CMS) begin to penalize hospitals for surgery readmissions. Hospitals and post-acute care providers are already making plans.
Post-operative safety measures are emphasized in the plan along with education and full-time registered-nurse resources for patients recovering in the home. Care in the home is the less costly option and is being considered as the number one place for patients to recover. This is to proactively prevent, detect and decrease avoidable readmissions which in turn enhance patient outcomes.
Safety measures include better pre-surgical preparation, patient education to prevent dehydration and site infections. Now enter post-acute care providers for round the clock care.
Post-acute care providers can monitor and care for the patient with intravenous antibiotic treatment to speech therapy to increase swallowing ability to avoid secondary conditions. Post-acute care providers work to reverse patient decline and to speed the recovery without returning to the hospital.
A care transition program is another way to improve the interaction between the hospital and post-acute care providers. Enhanced transitions in care can include a home care provider to meet with patients prior to surgery to address any issues and transfer knowledge to the patient and family. Additionally, medication management, patient goals and care plan can be discussed as well. This all makes for a seamless handoff from hospital to home care.
By engaging patients in their own care process using shared decision-making tools, understandable education, personalized information and communication strategies designed to reach diverse patient groups. The more engaged patients are in their care, the less likely they are to be readmitted to the hospital.