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Nursing Homes May Need to Improve Their Discharge Planning

Published March 17, 2014 1:55 PM by Brian Garavaglia

In a recent study conducted by the University of North Carolina at Chapel Hill, a high percentage of Medicare residents who are discharged from nursing homes often are re-hospitalized within 30 days. Individuals receiving care within nursing homes in which the care is being paid for by Medicare are often there after they have been discharged from the hospital and are in continued need of receiving rehabilitative care. Nursing homes in the United States have become increasingly used as a continuum of care within the rehabilitative process of many acute care patients. Although nursing home care is still predominately a chronic care enterprise, more nursing homes are being used as an intermediate phase for continued rehabilitation after the hospital is no longer able to maintain the patient and bill insurance for in-patient hospital services.   

Given that more patients, including a younger patient population, are using nursing home facilities as acute care rehabilitative services, the need to address appropriate discharge planning needs are becoming a rising concern with increasingly important ramifications for the health of the patient, as well as the economic costs for society. The current study may indicate that greater administrative organization may need to be untaken in the discharge area.   

The current study followed 50,000 Medicare residents who were treated within a skilled nursing home environment within North and South Carolina. The study found that approximately 22 percent of those Medicare beneficiaries that were being treated within the nursing home environment, with the expectation for discharge after rehabilitation, required emergency care within 30 days of discharge from the nursing home environment and 37.5 percent required some level of acute or hospital type care within 90 days of discharge from the nursing home. As one can see this is a high rate of return to the hospital after a supposedly successful rehabilitation. 

Demographic factors were also examined in the study to find out if there were any differences between certain groups. They found African Americans were more likely to need additional acute care services and subsequently be readmitted to a hospital after discharge from a nursing care facility. Additional factors were also found to be associated with the increased rate of return to the hospital such as being an older adult who suffers from cancer or respiratory disorders. Moreover, having a higher number of previous hospitalizations, having greater levels of comorbidity, and interestingly, receiving care from a for-profit nursing care facility, were associated with higher rates of hospital return.  

The study's authors are not sure how many of these re-hospitalizations or returns to the emergency room are preventable. Under the Affordable Care Act hospitals incur a penalty for readmitting Medicare patients. Therefore, hospitals have a monetary incentive to maintain patients from being re-hospitalized for the same conditions they were treated for previously within the hospital. One can see that this disincentive to readmit patients that hospitals have sent to a nursing home will not aid toward producing productive hospital-nursing home relationships. Furthermore, more has to be examined as to exactly where the problem lies and what has to be done to solve this issue. 

Nursing homes have taken on many new roles within the overall health care spectrum. One of these is the increasing dependence on nursing care facilities to take up the rehabilitative burden for hospitalized patients that no longer qualify for in-patient hospitalization. Since nursing homes are facing a greater rehabilitative burden, and since many are now becoming increasingly post-acute care environments that often have many non-traditional younger, as well as traditional older, long-term care clientele, the need for closer administrative and clinical sensitivity regarding the greater diversity of rehabilitative needs has to be cogently addressed. Along with this, increased sensitivity for out-patient or discharge care planning has taken on an increasingly important and demanding responsibility for nursing home professionals. This is not to say it has not been important previously, but as this study shows, it may have become an even more important skill in today's long-term health care environment. However, we also need to be cautious about extrapolating further on the results of this study. It looked at nursing home discharge and re-hospitalization in two states. Whether this may also be a significant issue in the other 48 states still needs to be answered more definitively. However, it does appear quite plausible that this may be a wide-spread issue that may be found throughout the nursing home industry. 

Since time spent within hospitals has decreased over the years, and since nursing homes have taken on an increasing amount of patient-care slack in the rehabilitation of patients, the need to pay greater attention to the rehabilitative and discharge needs of nursing home residents is becoming very important.   When you add this to the pressing economic issues of reducing health care costs, avoiding expensive hospital care through re-hospitalization has become an increasingly paramount issue. Furthermore, providing a targeted and specific form of rehabilitation for an increasingly diverse rehabilitative population that has not previously been part of the nursing home environment, including many younger individuals who were not normally a part of the long-term care environment, is becoming an increasingly pressing issue as well. A diverse and multifaceted rehabilitation population that is now becoming a natural part of the long-term care environment creates different skill-needs that need to be addressed by the physical, occupational, speech and activity therapists.  Furthermore, the psychosocial placement issues have increased dramatically, creating the need for greater skill in this area as well. Finally, the financial disincentives for re-hospitalizations found in the hospital environment need to bring greater collaboration between hospitals and nursing homes toward solving this potential problem, a collaboration that has often not existed between these two parts of the health care sector. Consequently, although more needs to be found through future studies regarding this issue, the current study may be an important sensitizer toward directing our attention and efforts toward solving an important issue that may be quite endemic within our country's nursing homes and among their post-acute care clientele.                 


University of North Carolina at Chapel Hill. (2014, February 20). "After nursing home discharge, many Medicare beneficiaries return to ER." Medical News Today. Retrieved from


Readmissions to the hospitals from LTC are more difficult for LTC facilities to tract due to the number of refering hospitals.  Our largest portion of readmissions to the hospital are patients that do not follow the recommendations for a safe discharge. When patients DC to inappropriate environments rehospitalization rates elevate dramatically, many times with negative outcomes such as a fracture.  APS consults and home care with nursing and SS don't seem to change these negative outcomes when the placement is inappropriate.  Assisted Living is being used as a substitute for a SNF or families are taking patients home and can't provide the supervision needed.  We spend weeks on discharge planning, home visits, and care conferences, and having families work with therapy

a ferrari April 4, 2014 6:36 PM

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About this Blog

    Brian Garavaglia, PhD
    Occupation: Long-term care administrator
    Setting: Sterling Heights, Mich.
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