Saralin TiedemanPOST-ACUTE UDATE

By Saralin Tiedeman, MS, OTR/L, Post-Acute Project Manager

According to the Western New York Community Needs Assessment which was completed in 2014, our baseline Potentially Avoidable Readmission rate is 5.8/100 patients. Niagara, Orleans, and Chautauqua Counties are nearly double the goal rate, with a rate as high as 8.9/100 patients. There are many chronic conditions driving these high readmission rates, namely Diabetes, COPD/Asthma, and Heart Failure.

When we look at the skilled nursing facility to hospital admissions for Medicaid beneficiaries for New York State, the rate in 2014 was 1.5/100 beneficiaries.

In WNY, our average was 5.8/100 beneficiaries, nearly quadruple the State average. Coincidentally, the Home Care potentially preventable readmission (PPR) rate was also 5.8/100 beneficiaries in 2014.

One way we as a network can work collaboratively to lower these hospital admission and readmission rates is to concentrate on ensuring effective discharge planning for our patients.

  • Are we currently discharging our patients with all they need to succeed?
  • Have they been fully educated on their chronic conditions, their medication, their prognosis?
  • Has an effective conversation surrounding advance care planning occurred?

These are all elements to a good discharge protocol that need to be addressed prior to discharge.

The Re-Engineered Hospital Discharge Program (RED) is a model which was implemented in the acute care setting that consists of 12 mutually reinforcing components that define a high quality discharge.

This model has been endorsed by the National Quality Forum and forms the basis for the NQF “Safe Practice” on hospital discharge. All 12 components have relevancy in the Post-Acute Care setting and could be implemented into our current discharge process to ensure we are indeed setting our patients up to succeed once they leave our care.

The Program focuses on improving the key tenants to a successful discharge including:

  • Patient understanding
  • Patient engagement
  • Patient self-management skills
  • Care coordination with the community physician
  • Medication management
  • Health literacy and cultural competency

Through the use of patient discharge care plans, teach-back and motivational interviewing strategies, and post-discharge follow-up, the RED program has demonstrated a significant improvement in readmission rates in hospitals across the country. This program may serve as an ideal model for the Post-Acute Care network to implement in order to lower our region’s admissions and readmissions, as well as improve health outcomes for the patients in our communities.



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