Collaborating with healthcare providers is the key to reducing hospital readmission rates for senior living residents, San Diego-based Senior Resource Group believes. And the owner, developer and operator of 32 communities has data to support that belief.
“Being discharged from the hospital doesn’t always mean a patient has fully recovered,” said Isaac Hagerman, vice president of health and quality at SRG. “In many cases, they haven’t, which can make that transition back to normal life challenging.”
The trademarked SRG Assure program, he added, “offers those residents receiving supportive care services a specialized focus, both during a hospital stay and after being discharged back to the community, all within a service-enriched, residential living environment.”
Program administrators work with hospitals, discharge planners and others to reduce hospital readmission rates by focusing on the key factors that can contribute to the likelihood of readmission, SRG said.
- Resident health information is provided to serve as a baseline when the older adult is admitted.
- Care is coordinated when a resident is discharged and returns to the senior living community.
- Physician orders are implemented “quickly and completely.”
- Prescription orders are tracked to ensure that residents are taking medications at the right time, and in the right dose, in coordination with SRG’s medication management services.
- Modifications to the residence, if needed, are coordinated, as are modifications to the onsite rehabilitation services area.
- A follow-up appointment is coordinated within seven days of the person’s discharge.
- Around-the-clock access to a registered nurse who can help assess changes in resident condition and to establish an action plan is planned.
- Training and outcome data will be collected on an ongoing basis.
Once a resident has transitioned back to his or her senior living community during the recovery period, SRG’s evidence-based wellness program, called ZEST, can foster good health as well, with its focus on minimizing decline and maintaining activities of daily living function in residents, according to SRG.
By focusing on the key factors that can contribute to the likelihood of a resident being readmitted to the hospital, SRG said, 30-day readmission rates are now less than 10%. With outcome-tracking data for more than three years, the 12-month rolling average as of June is 9.2%, according to the company. That’s with an average resident age of 84, whereas the national 30-day readmission rates is 20% and includes those aged 65 or more years.
Additionally, SRG said, 8.8% of residents of the company’s communities went to the emergency department in January compared with the senior living industry national average of 14%, based on data from the Centers for Disease Control and Prevention’s National Center for Health Statistics.
Also in January, 12.9% of SRG residents fell, compared with a national average of 22% for senior living residents.