Patients discharged from an acute care hospital to an acute rehabilitation facility are more likely to be readmitted to the hospital within 30 days if they score poorly on the Functional Independence Measure (FIM) test, which measures a persons ability to perform activities of daily living, according to a study at Johns Hopkins Medicine.
Transitions from the hospital go smoother and patients are less likely to be readmitted when the providers at the next level of care get detailed and complete information about the patient, says Sandy Merlino, RN, MBA, vice president, integrated delivery systems and hospital market development for Visiting Nurse Service of New York.
More hospitals than ever before are being penalized by the Centers for Medicare & Medicaid Services for excess readmissions and insurers are starting to develop their own readmission reduction programs.
The CMS efficiency measure has once again raised the issues of length of stay management and cost reduction. These have always been a component of the role of the hospital-based case manager. In todays best practice models, these interventions must be correlated with the roles of coordination and facilitation of care, discharge planning and utilization management. The case managers roles and functions, as well as staffing ratios, must be designed in such a way as to allow for this integration of roles. Be sure that your department is focusing on how to embed this important function in your everyday practice!