Skilled nursing facilities are now included in the complex process of reducing hospital readmissions for the residents where we are providing care.  As of July 1, 2016, the frequency of residents returning to the hospital within 30 days for further treatment is being tracked and financial penalties are at risk. These will be assessed if the readmission rate is greater than the national average.  Currently that rate is 15% and the Illinois average is 22%.   These fines will go into effect in 2018, so now is the time to determine the readmission rate in a facility and take steps to reduce it.

Although specific diagnoses and conditions have been identified as the focus of this program, many of them have a significant nutrition component.  Heart failure, myocardial infarction and pneumonia were the first ones to be monitored; frequent readmission are noted for COPD, low BMI, pressure ulcer, UTI and now hip and knee replacements will be added to the group.

Causes of readmission include:

  • Worsening of patient condition after discharge
  • Lack of follow-up after discharge
  • Poor quality of care
  • Poor care coordination during the transition.

Dietitians and dietary managers are ready to be active participants in the quality assurance and performance improvement team of the skilled nursing facility.

Every resident in the skilled facility has an assessment completed by the dietary manager and the dietitian to develop a plan of care and monitor the results of that plan.  Weekly weight monitoring is key during that initial period.  Meals and snacks, dining acceptance, medication interactions with appetite are part of the role these nutrition professionals are monitoring.  Adjustments to the diet, eating location, assistance needed or referral to speech therapy, if indicated, are all steps which are valuable to ensure the resident has the best possible outcome in the skilled setting.  Diets are liberalized to enhance meal acceptance and intakes to meet nutritional goals.

Continuation of the healthcare plan which was developed in the hospital and communication with the hospital, if necessary, will help to ensure the nutrition plan of care will be fully implemented.  Diet education can be provided or supplemented as the resident is preparing to be more responsible for their own eating plan during the transition from acute care to skilled care and eventually home.  The consultant dietitian has an important overview of the health and nutritional condition of the long term care resident. The dietitian is ready to take on additional roles of communication and follow-up to help reduce hospital readmissions. This nutrition expertise can save a facility the financial penalties that are lurking on the horizon.