The Role of Hospitalists in Smooth Transitions of Care

Readmission rates are an essential care metric for skilled nursing facilities (SNFs). While higher rates of readmission can indicate a lower quality of care, they also come at a cost. In 2018, it was estimated that the average cost of readmission was $16,037 — and this cost has likely only climbed over the years.

With the implications of readmissions, SNFs need to find better ways to deliver care, especially in care transitions post-discharge. Hospitalists are a key piece of this puzzle. These physicians provide critical leadership, collaboration, and oversight for skilled nursing centers. The impact of hospitalists on readmission rates is a positive one — presence, collaboration, and clinical best practices can reduce readmissions and improve patient outcomes. 

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Understanding Readmissions in Healthcare

Hospital readmission occurs when a patient has been discharged from a hospital and has to return the same or related care within 30, 60, or 90 days. Readmission rates are typically used as a quality measure for skilled nursing centers because they can signify a lower quality of care. Common causes of readmission include:

  • Medication errors 
  • Lack of follow-up care
  • Low patient engagement
  • Chronic conditions
  • Infections of surgical sites

While some causes of readmission are hard to prevent, others can be mitigated with better care transitions. Approximately one in four patients discharged from a hospital to a SNF will be readmitted within 30 days. With strategies for smooth transitions of care, SNFs can find ways to disrupt this trend. Doing so can positively affect care outcomes and offer financial benefits, particularly since hospital readmissions equate to around $5.2 billion in Medicare costs annually

The Challenges of Care Transitions

Care transitions are vital to care outcomes, but they come with challenges like:

  • Communication gaps: Multiple providers are responsible for a patient’s care during their stay at your center. When these providers fail to communicate observations and care needs, overall care becomes disjointed. In some cases, this lack of communication can result in two care approaches that contradict each other, which may lead to poor outcomes. 
  • Lack of follow-up: A patient’s care needs change as their condition shifts. The care plan they left your facility with may not be what they need in a few weeks. Follow-up is essential for staying informed about a patient’s condition and adjusting as required to support the best possible outcomes.
  • Insufficient patient education: Once a patient leaves your SNF, they become accountable for their own care. When patients and their families don’t fully understand care instructions, they’re less likely to follow through. And the data agrees. Patients who understand their physicians’ instructions have 30% fewer return visits. Conversely, people who don’t understand health information are more likely to have health problems and less likely to get preventive care.

As a result of these challenges in care transitions, patient and resident outcomes suffer. When care needs are not clearly communicated and patients are not held accountable for their post-discharge care instructions, conditions worsen and rehospitalization rates rise.

The Role of Hospitalists in Patient Care

Hospitalists are internal medicine physicians who specialize in inpatient care. The focus of this role is care coordination and leadership. Hospitalists will often order different tests and delegate tasks to other care providers, as well as ensure care is consistent and effective for each patient and resident’s unique needs.

While these providers often work in hospitals, they’re also commonly hired in skilled nursing centers. In these practices, hospitalists play the role of medical directors and attending physicians. As they would in a hospital setting, these providers focus on leading care teams and ensuring effective delivery of care. 

In a SNF environment, this role is essential for complying with the medical director requirements set by the Centers for Medicare and Medicaid Services (CMS). This leadership role is required to drive a higher quality of care and prioritize quality metrics, like reducing rehospitalizations and improving patient satisfaction. Hospitalist-led care in skilled nursing facilities can also support smoother transitions of care.

Strategies for Reducing Readmissions Through Effective Care Transitions

While a hospitalist operating as your medical director and attending physician can support effective care transitions, there are other strategies your facility can use, including:

  • Enhance communication: Your facility needs to align with the providers at the hospitals you’re accepting patients from. Connecting with these providers will clue you in to the key aspects of a patient’s care and ensure your team follows through with the next steps. Keeping open lines of communication is also critical during a person’s stay as well as following discharge.
  • Improve care coordination and management: One of the core roles of a hospitalist in care transitions is coordinating care. When you transition a patient to your SNF, your medical director will work with the providers at your center to deliver the appropriate care.
  • Increase patient education and engagement: Patient education is valuable for adherence to care plans post-discharge. When a patient understands the reasoning behind their care plan, it makes it easier to follow through. Providers should work together to provide patient education and prevent readmissions.
  • Use technology: Electronic health records (EHR) streamline information sharing. When providers can easily document patient updates and share them with other staff members, collaboration is more accessible and care plans are more informed. 

First Docs: Improving Patient Outcomes With Hospitalists

First Docs is a physician-first group dedicated to resolving challenges for facilities like SNFs. Our physicians have hospitalist training and operate as your center’s dedicated medical director and attending physician. With their leadership, your staff becomes more collaborative with shared quality objectives and ongoing clinical guidance.

Our physicians are on-site at your center five to seven days a week — well above the average for other hospitalists. First Docs physicians also focus on fewer facilities to give their time and attention to your complex patient and resident population. Count on your First Docs physician to lead your staff and support CMS compliance through medical director hours and QAPI meetings.

With improved care continuity and a more connected clinical environment, your facility can improve care transitions and reduce readmissions.

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Contact First Docs Today

Hospitalists reduce SNF readmission rates through leadership, collaboration, and an in-depth understanding of patient and resident needs. With First Docs, the hospitalist at your center is more committed than most. With time dedicated to fewer facilities, our physicians understand the complexities of your SNF population and work to facilitate effective care. Get in touch with us today to get started.

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