Discharges and Readmissions: Essentials for a Smooth Handover

Video Runtime: 39 Minutes; Learning Assessment Time: 35 Minutes

Gaps in the transitional care process may escalate when a patient is discharged from a structured environment of care to their home or other community site of care. These gaps may contribute to the development of negative healthcare outcomes that might be a direct cause of a readmission to acute care. Although the rates of hospital readmissions have diminished slightly since 2014, the Centers for Medicare & Medicaid Services (CMS) will penalize more than 2,500 hospitals in fiscal year 2021 for readmission rates that exceed national averages. In addition to readmissions associated with a discharge from an acute care hospital, CMS has developed specific quality measures for post-acute care that focus on potentially preventable readmissions during the post-acute stay and following discharge from the post-acute facility. Closing these gaps is vital to balancing patient advocacy and fiscal accountability.

Studies have demonstrated that a majority of negative outcomes and serious medical errors are associated with communication gaps occurring during care transitions. This course will focus on the development of specific initiatives employed by the transdisciplinary team to support effective communication strategies as the patient transitions to the next level of care and the next setting of care. This course is applicable to physical therapists, occupational therapists, speech-language pathologists, nurses, social workers, and case managers.