Published On: 02-01-2021

Recently, there have been numerous policy and program responses to reducing potentially avoidable hospitalizations from skilled nursing facilities (SNFs). It is estimated that approximately 25% of resident discharges to SNFs are readmitted within 30 days of discharge. Medicare spends more than $14 billion annually on both short- and long-stay SNF resident hospitalizations, many of which are preventable and unnecessary. Models have been proposed that focus on the relationships between nursing home (NH) physicians and staff of SNFs to reduce rehospitalizations. Other models applying complexity science principles of building relationships create the capacity for delivering better care.6 Evidence examining the level of physician engagement in SNFs suggests that rehospitalizations can be reduced with higher physician engagement. In addition, there is growing evidence supporting the importance of the use of specialty staff, such as nurse practitioners and physicians, with a variety of clinical expertise to augment resident care provided by traditional or standard NH staff. One such model was developed using advanced practice registered nurses (APRNs), a clinical support team, and a medical director with a specialty in geriatrics to augment NH staff to reduce potentially avoidable hospitalizations.

Galambos, C., Vogelsmeier, A., Popejoy, L., Crecelius, C., Canada, K., Alexander, G., Rollin, L., & Rantz, M. (2021). Enhancing physician relationships, communication, and engagement to reduce nursing home residents hospitalizations. Journal of Nursing Care Quality, published online February 2021.

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