Maintaining patient health after a hospital stay...
RARE - Reducing Avoidable Readmissions Effectively

Long Term Care

Nursing homes may want to track hospital admissions and readmissions for a number of reasons.

Reduce Burden

  • While many admissions/readmissions are necessary, some are avoidable. Preventable hospital admissions/readmissions place a significant physical and emotional burden on patients and their families. Avoiding these transfers will alleviate this burden and will allow residents the comfort and wellbeing of sleeping in their own beds.
  • Transferring residents to and from hospitals creates a lot of work for staff.

Reduce Costs

  • Avoidable hospitalizations are very costly. The Centers for Medicare & Medicaid Services (CMS) and other payers are increasingly interested in improving coordination of care and are focusing on the topic of avoidable hospitalizations.
  • Hospitals will bear financial risk for readmissions related to select conditions per provisions in the Patient Protection and Affordable Care Act. Hospitals with higher than expected risk-adjusted 30-day readmission performance can incur CMS penalties up to 1 percent of their total inpatient Medicare payments beginning in fiscal year 2013 (i.e., starting Oct. 1, 2012). The penalty increases each year after that. Nursing homes should act now to prevent readmissions. They will benefit by demonstrating to hospitals that they can help prevent avoidable readmissions, by successfully and effectively managing resident care.
  • CMS recently announced a demonstration project focused on reducing preventable hospitalizations among residents of nursing facilities.

Improve Quality

  • Tracking hospital admissions/readmissions allows nursing homes to find and address problematic patterns. Action plans can be developed to address issues on a particular unit/shift. This work integrates with a nursing home's wider efforts to improve quality of care and residents' quality of life.
  • Nursing homes have new Quality Assurance Performance Improvement (QAPI) provisions in the 2010 Affordable Care Act. When fully implemented, a QAPI program should address clinical care, quality of life, resident choice, and care transitions.
  • Quality Indicator Surveys (QIS) sample 30 admission charts of people admitted to the nursing facility. The Stage 1 investigation generates a readmission rate—QP058 Hospitalization Within 30 Days—as one Quality of Care and Quality of Life Indicator. If the threshold of 15 percent is exceeded, then a Stage 2 investigation is triggered for the care area of hospitalization. Nursing homes will want to be familiar with their readmission rates and use this information with a broader-based review to gain insights on ways to reduce hospital readmissions.

Public Reporting

  • For hospitals and home health agencies, CMS currently publicly reports on their readmissions and admissions, respectively. Public reporting for nursing homes on these topics could occur in the future.
  • The Minnesota Department of Human Services is in the process of developing a risk adjusted readmissions measure for nursing facilities.


Why Nursing Homes Should Track Hospital Admissions/Readmissions. This document is a printable version of the information above. (2-page Word doc)

Advancing Excellence - hospitalization resources. These resources assist nursing home staff to safely care for residents onsite using evidence-based and expert recommended tools and practices to reduce rates of hospitalization without compromising residents’ well-being or wishes.

Hospital Admission Discharge Tracker 2011. The spreadsheet was developed by the RARE Campaign as a tool to help nursing facilities calculate two types of rehospitalization measures: 1) The Minnesota Department of Human Service Rehospitalization Measures and 2) Other Rehospitalization Measure.

Hospital Readmission/ER Visit Data Collection. This form is intended to track the number and characteristics of all unplanned nursing home resident transfers or visits to the hospital or emergency room. Developed by Care Choice, a cooperative of not-for-profit, mission- driven providers of aging services, based on the INTERACT model.

INTERACT. The INTERACT (Interventions to Reduce Acute Care Transfers) program includes clinical and educational tools and strategies for use in every day practice in long-term care facilities.

Partnering to Avoid Hospital Readmissions. Presentation to the Aging Services of MN 2012 Institute. Presenters: Kathy Cummings, RN, BSN, MA, Institute for Clinical Systems Improvement and Janelle Shearer, RN, BSN, MA, Stratis Health. (21-page PowerPoint)

Webinar on Home Care and Reducing Hospital Readmissions. This webinar discusses the role of home care in reducing hospital readmissions. Home care encompasses a wide range of health and social services delivered to recovering, disabled, chronically, or terminally ill persons in their own homes. The webinar speaker is Jennifer Sorensen, Executive Director, Minnesota HomeCare Association. (Recorded December 14, 2011) (47-minute webinar) Handout (12-page PDF)

Webinar on Long-Term Care and Hospital Admissions/Readmissions Data Collection. Preventing avoidable admissions/readmissions provides opportunities to achieve the Triple Aim of improving population health, the patient experience and the affordability of care. Representatives from the RARE Campaign's Long-term Care Work Group discuss the importance of tracking hospital readmissions from long-term care facilities. They describe two tracking tools available to long-term care facilities as part of the RARE Campaign. (Recorded November 8, 2011) (45-minute podcast)

  • Hospital Admission-Discharge Tracker 2011, Todd Bergstrom, Director of Research and Payment, Care Providers of Minnesota, Handout (10-page PDF)
  • Resident Centered Care Connections, Susan Peterson, RN, BSN, CHPN, CareChoice Resident Centered Care Connections, Handout (6-page PDF)
  • Kelly M. O'Neill, RN, BSN, MPA, CPHQ, Stratis Health, Handout (7-page PDF)

Webinar on Transitions to End-of-Life Care: Difficult Discussions. This webinar outlines key factors that can be conversation starters between patients, family members, and clinicians about end-of-life care. The webinar speaker is Lores Vlaminck, RN, BSN, MA, CHPN, Lores Consulting. Vlaminck is a seasoned professional in the fields of home care, palliative care, hospice, and assisted living. (Recorded March 21, 2012) (58-minute webinar)

  • Categories EPERC Handout (6-page Word doc)
  • Lores Vlaminck bio Handout (1-page Word doc)
  • Palliative Pocket Cards Handout (2-page PDF)
  • Ten Steps to Better Prognostication Handout (1-page PDF)
  • Transitions to End of Life Care: Difficult Discussions Slides (46-slide PowerPoint)
Patients and family members
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RARE is a campaign lead by the Institute for Clinical Systems Improvement, the Minnesota Hospital Association, and Stratis Health, which represents Lake Superior Quality Innovation Network in Minnesota.