Hospital readmissions are traumatizing and disruptive to the lives of patients and families. Nationwide, almost a quarter of all patients with Medicare return to the hospital within one month of discharge. Seventy-five percent of Medicare hospital readmissions (4.4 million) may be preventable, potentially saving up to $12 billion in annual Medicare spending. More than 50 percent of readmissions are found to be related to some type of medication problem.

From a skilled nursing perspective, one in four Medicare patients admitted to skilled nursing facilities from hospitals is readmitted to the hospital within 30 days. Up to two-thirds of those hospital transfers are avoidable. atom Alliance is working with providers to reduce those readmission rates through coordination of care among provider settings within communities.

A key to reducing readmissions is reconciling medications at the time of admission to the skilled nursing facility, particularly medications which present a high risk for adverse drug events, such as anticoagulants, diabetic agents and opioids.

Contracted by the Centers for Medicare & Medicaid Services (CMS), atom Alliance partners with nursing homes to reduce hospital readmissions using evidence-based strategies such as INTERACT. INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program that focuses on management of acute changes in residents’ conditions. This program includes clinical and educational tools and strategies for use in everyday practice in long-term care facilities.

INTERACT Quality Improvement Tools:

• Aid in analyzing hospital transfers and identifying opportunities to reduce potentially preventable transfers,
• Enhance documentation of factors contributing to the transfer,
• Guide staff in tracking hospital transfers and
• Help identify common factors in hospital transfers to focus education and care process changes.

For more information on the INTERACT quality improvement tools, go here.

Learn more about atom Alliance Care Coordination Communities.

Janet Pollock, BA, Qsource Community Manager

Janet is the Community Manager for Qsource, the Kentucky Quality Improvement Network-Quality Improvement Organization (QIN-QIO) and atom Alliance member. Her QIO work includes 12 years of community collaboration in provider initiatives including nursing homes, pharmacy, hospitals, care transition communities and patient-centered care. Her goal is to promote individualizing care and processes to improve healthcare culture for patients, families and staff of nursing homes, hospitals and healthcare organizations. Janet has also served as a long-term care ombudsman and coordinator with the State Health Insurance Program (SHIP), presenting at community, civic and provider meetings on various health care promotion and disease prevention topics.