Reducing Hospital Readmission from Skilled Nursing

REDUCING READMISSIONS FROM SNF 1

Reducing Hospital Readmission from Skilled Nursing Facilities to Reduce Healthcare Costs

and Improve Quality of Care

Morgan N. Ekstrom

Annie DeRolf, OTD, OTR, Doctoral Capstone Coordinator, Faculty Mentor; Anthony Chase,

PhD, Assistant Professor

Indiana University Purdue University Indianapolis

Department of Occupational Therapy


Acknowledgements

I would like to thank everyone who has helped and supported me throughout this project

and my journey of earning my occupational therapy doctorate.

Thank you to my faculty mentor, Dr. Annie DeRolf, OTD, OTR, Doctoral Capstone

Coordinator, for your support, guidance, and feedback throughout the capstone experience. I am

grateful for the expertise and direction of Dr. Anthony Chase, PhD Assistant Professor, who

assisted with the statistical analysis. Thank you to my advisor, Dr. Julie Bednarski, OTD, MHS,

OTR, Clinical Associate Professor and Program Director for your encouragement and advice

throughout the program and each stage of the capstone planning and implementation process.

A special thank you to my site mentor, the therapy team, and patients at my site. It was a

pleasure working with all of you. This project would not have been possible without your

involvement and feedback.

Finally, thank you to my family, especially my husband, Jorden, and my parents, Laura

and Brent, for their love, encouragement, and support as I work towards achieving my goals. I

would not be where I am today without you.


Table of Contents

Abstract .............................................................................................................................. 5

Reducing Hospital Readmission from Skilled Nursing Facilities to Reduce Healthcare

Costs and Improve Quality of Care............................................................................................. 6

Needs Assessment ............................................................................................................... 7

Literature Review.............................................................................................................. 10

Causes of Hospital Readmissions ................................................................................. 10

Strategies for Reducing Hospital Readmission Rates ................................................... 12

Readmissions at Skilled Nursing Facilities................................................................... 14

Role of Occupational Therapy .................................................................................. 15

Gap Analysis ................................................................................................................. 16

Guiding Model .................................................................................................................. 16

Project Plan and Process ................................................................................................... 18

Project Plan ................................................................................................................... 18

Project Goals ................................................................................................................. 18

Project Process .............................................................................................................. 20

Project Implementation ..................................................................................................... 21

Retrospective Cohort Study .......................................................................................... 21

Results of Data Analysis ........................................................................................... 23

Patient Interviews.......................................................................................................... 26


Patient Interview Results .......................................................................................... 26

Therapist Survey ........................................................................................................... 27

Therapist Survey Results ........................................................................................... 28

Recommendation and Resource Development ............................................................. 28

Project Evaluation ............................................................................................................. 31

Results ........................................................................................................................... 32

Discussion ......................................................................................................................... 33

Impact ........................................................................................................................... 35

Sustainability................................................................................................................. 36

Conclusion ........................................................................................................................ 37

References ........................................................................................................................ 38

Appendix A ....................................................................................................................... 41

Appendix B ....................................................................................................................... 43

Appendix C ....................................................................................................................... 44

Appendix D ....................................................................................................................... 47

Appendix E ....................................................................................................................... 48

Appendix F........................................................................................................................ 50

Appendix G ....................................................................................................................... 57


Abstract

Patients discharged to skilled nursing facilities after hospital stays experience high readmission

rates due to insurance mandating length of stay. This study used mixed methods to determine

patient characteristics that contribute to readmissions and develop recommendations to reduce

readmissions. The medical records of 241 patients discharged from a skilled nursing facility

(SNF) were reviewed to identify common characteristics of individuals who readmitted in 30 or

60 days. Data was analyzed using an independent samples t-test and binary logistic regression

analysis. There was a significant difference in average SNF length of stay, number of

comorbidities, and self-care and mobility scores of patients readmitted in 30 days and those who

did not. There was a significant difference in SNF length of stay, more comorbidities, self-care

and mobility scores, and number of risk factors of patients readmitted in 60 days and those who

did not. Binary logistic regression showed short SNF length of stay, congestive heart failure, and

more comorbidities predicted a readmission in 30 days. Similarly, diabetes, more comorbidities,

and not receiving home health predicted readmissions in 60 days. Qualitative data was collected

from patient interviews to gain perspectives on the quality of care at the SNF and therapist

surveys to determine their understanding of readmissions and their proposed solutions for

readmissions. Recommendations included improving communication between staff and patients,

increasing patient education, and providing therapy discharge instruction to ensure successful

discharge. The results propose possible reasons for readmissions and ways to reduce them to

improve patient outcomes and decrease healthcare spending.

Keywords: patient education, caregiver training, communication, chronic condition

management


Reducing Hospital Readmission from Skilled Nursing Facilities to Reduce Healthcare Costs

and Improve Quality of Care

The healthcare industry is constantly striving to provide high quality patient care while

controlling healthcare spending. One contributing factor to high healthcare costs is hospital

readmissions. High hospital readmission rates are a well-known problem in the medical

community, but there is insufficient research on what can be done to improve them. Skilled

nursing facilities (SNFs) in particular have higher readmission rates than any other discharge

location (Rosen et al., 2018). Researchers found that 1/4 patients who were discharged to a

skilled nursing facility (SNF) were readmitted within 30 days, and 2/3 of those readmissions

were believed to be preventable (Neuman et al., 2014). For this study, a partnership was formed

with a skilled nursing facility (SNF) that is part of a larger network of senior living communities

across the state of Indiana which are owned and operated by the same company. This SNF

focuses on providing holistic and personalized care based on the patients’ ability level in order to

facilitate their recovery following hospitalizations. This facility offers physical, occupational,

and speech therapy along with nursing staff, social workers, and administrative staff all

dedicated to providing high quality care for the patients. The site has 176 beds and serves

primarily older adults with a wide variety of acute and chronic conditions such as diabetes

complications, strokes, joint replacements, and general debility.

The focus areas of this study were Quality Improvement and Program and Policy

Development which aimed at improving quality of care for skilled nursing facility patients and

while reducing health care costs. Hospital readmissions have financial implications for both the

company who owns the SNF as well as the insurance company. In 2011, Medicare spent 14.3

billion on rehospitalizations from SNFs (Yoo et al., 2015). In addition to the cost, these


unplanned readmissions are used as a quality metric, so it is important for health care providers

and payers to determine what can be done to reduce them. It is also important for patients as

they deserve the best quality of care available (Chandra et al., 2019). Rehospitalization causes

stress, adverse events, and decreased quality of life for patients (Mendu et al., 2018). Finding a

solution to this continuous cycle would provide better quality care for patients, improve patient

outcomes, and reduce health care costs. This SNF provided good context for this focus area

because they experience high readmission rates and they were motivated to make the changes

necessary to improve patient outcomes and decrease spending. Therefore, the purpose of this

project was to identify common causes for readmission and develop a program that will help the

facility better prepare the patients for discharge in order to improve patient outcomes and

decreased readmission rates.

Needs Assessment

In order to learn more about the site, a needs assessment interview was conducted at the

facility with the Director of Therapy for the company and a Senior Therapy Supervisor for one of

their SNFs. In the beginning, the questions were focused on learning more about the facility, the

population they serve, and potential project options (See Appendix A for interview

questions). As the need was identified, questions became more specific in order to further

understand the problem and what could potentially be done to address it.

Throughout the interview, a common theme that emerged was decreased quality of care

being provided due to lack of time with patients. Further discussion revealed that a major

problem within this network of SNFs was short lengths of stays caused by insurance regulations

(Director of Therapy, personal communication, October 22, 2019). The Senior Therapy

Supervisor explained that these short lengths of stays cause patients to be discharged before their


prior level of function is reached (personal communication, October 22, 2019). They believe

that this contributes to patients being readmitted to the hospital after being discharged from the

SNF because they do not have adequate time to fully treat the patient prior to discharge. When

admitted to skilled nursing facilities, patients are often under the impression that they will stay

until they are fully recovered. Unfortunately, this is not necessarily the case. Currently, the

length of time patients can stay in the SNF is largely determined by insurance companies who

limit the patients’ length of stay in order to manage health care costs. This can make it

challenging to providing high quality care and often contributes to patients being readmitted to

the hospital. The company would like to reduce this cycle in order to provide better care for

their patients.

Another common theme discussed was the role of Home Health services in preventing

readmissions. Since patients are being discharged before prior level of function is reached, many

of their patients go on to receive home health services, but it is unclear if that level of care is

sufficient for the patient to regain functional independence. The final theme that emerged was

spending. The company is motivated to improve readmission rates because it is costly for the

facility and insurance companies when patients are readmitted within 30 days. Based on the

interview and the facilities current need, it was determined that the topic of this project would be

determining why patients are being readmitted to the hospital and what could be done to prevent

it in order to provide better care for patients and reduce health care costs.

In order to gain a better understanding of the facility as a whole and the therapy patients

receive prior to discharge, the researcher shadowed an occupational therapist at the SNF. The

knowledge obtained from shadowing helped inform decisions in the early stages of planning.

After being onsite, key stakeholders expressed a need to obtain the patients’ perspective on the


quality of care they are receiving at the SNF and what concerns they have about returning home

in order to fully understand this problem.

In terms of assets, this SNF had therapists who were committed to providing the best care

possible for patients and corporate employees who are motivated to reduce costs of the facility

by decreasing money spent on readmission. They also have a partnership developed with a home

health agency. This was beneficial because there is the potential to share data between home

health and the SNF so they can identify patient declines early on and get them the care they need

rather than letting it progress to where the individual has to be readmitted to the

hospital. Another asset is the company’s new Director of Transitions position that can be

utilized to improve the transition from the SNF to the patients’ homes. These factors were

beneficial while working towards the overall goal of identifying what causes readmissions and

determining what they could do to prevent it.

There was a gap between how much time therapists were able to spend with patients

according to insurance and how much time was needed to return the patients to their prior level

of function. There was also poor communication between the patient and the healthcare team

that caused misunderstandings about the process and plan of care. Additionally, there was a

deficit in the therapists’ knowledge and the resources available to help them better prepare

patients for discharge which was leading to patient readmissions. Improving these deficits

enabled the SNF to provide better care for patients and decrease readmissions.

Overall, the problem the SNF was facing was that insurance companies mandating length

of stay for patients in their skilled nursing facilities was contributing to high hospital readmission

rates. This was costly for both the SNF and the insurance companies and decreased the quality

of life of their patients.


Literature Review

In order to examine current research regarding readmission rates from skilled nursing

facilities, the researcher identified articles that would be beneficial for the planning and

implementation of this project. The databases that were search were CINAHL Complete,

PubMed, and Embase. The search terms that were used were rehospitalization, hospital

readmission, skilled nursing facility and SNF. To get the most recent information, the literature

was limited to articles published in the last 10 years. The articles were screened by the

researcher and included in the study based on relevance to research topic and project goals.

Causes of Hospital Readmissions

Current research proposes a wide variety of possible causes for the high number of

hospital readmissions including patient, SNF, and hospital related factors. Chandra et al. (2019)

found that longer hospital stays, abnormal lab values, intensive care unit stay, comorbidities, and

higher number of emergency room and hospital visits in the last 6 months were all associated

with a greater risk of rehospitalization. The length of hospital stay was the strongest risk

predictor because patients with long hospital stays were more likely to have had complications

and be more debilitated (Chandra et al., 2019). According to patients, the quality of care they

received at the SNF contributed to majority of readmissions (Jacobsen et al., 2017). Neuman et

al. (2014) studied the quality of the SNF as one potential cause, but it was not consistently

associated with higher readmissions. They found that low staff ratings and low facility

inspection ratings were associated with slightly higher readmission rates, but other performance

measures such as patient pain and delirium were not associated with higher readmissions.

Neuman et al. (2014) also recorded patient characteristics and found that readmissions

within 30 days were more common for patients who are older, male, black, and who have


comorbidities such as coronary artery disease, diabetes, or chronic obstructive pulmonary

disease. The most common diagnoses of those readmitted were general medical conditions,

pulmonary conditions such as pneumonia, congestive heart failure, cardiac or vascular

conditions, septicemia, and urinary tract infections (Neuman et al., 2014; Yoo et al., 2015).

Similar to Neuman et al. (2014), Yoo et al. (2015) found race as a possible contributing factor as

rehospitalization was more common in black patients than white patients (18.6% versus 14.3%),

but they had differing results on the effect of delirium. Yoo et al. (2015) found that patients with

delirium were twice as likely to be rehospitalized whereas Neuman et al. (2014) found that there

was no association. Other common predictors of readmission were patients with ulcers,

functional impairments and abnormal lab values (Yoo et al., 2015). Middleton et al. found that

patients with greater mobility, self-care, and cognitive deficits have a significantly higher

likelihood of experiencing a preventable readmission (2018).

Other research focused less on patient factors and more on the quality of care being

provided by both the hospital and the SNF. It was reported that “poor quality of inpatient care,

inadequate staffing, inadequate discharge planning and premature discharge, improper transitions

of care, insufficient follow up, lack of care coordination, and poor communication between PAC

[post-acute care] and acute providers” were all factors that may contribute to avoidable

readmissions (Gupta et al., 2019, p. 2). Some of these factors such as premature discharge may

not be avoidable in all cases since insurance companies typically mandate length of stay in the

SNF, however, SNFs can find ways to maximize the time they do have with the patients.

According to SNFs, inadequate goal of care planning, end of life management, outpatient

treatment coordination, and preparation of families for transitions (Mendu et al., 2018).

Similarly, Berkowitz et al. (2013) found that “lack of resources in the SNF, poor communication


during transitions of care, and lack of patient and family engagement in understanding their

medical problems and plan of care” contributed to avoidable rehospitalizations (p. 736).

Strategies for Reducing Hospital Readmission Rates

One of the most common strategies suggested to address rehospitalization rates is

identifying at-risk patients when they arrive at the SNF. In order to do this, skilled nursing

facilities can adopt a risk prediction model that would track characteristics such as length of

hospital stay, abnormal lab values, comorbidities, and previous hospital and nursing home stays

which have been found to be associated with rehospitalizations (Chandra et al., 2019; Yoo et al.,

2015). The health care providers at the SNF could then provide specialized care and extra

resources to these patients to ensure their needs are met. It is also important to improve the

patient’s self-care abilities and mobility as well as provide resources and caregiver education

prior to discharge in order to increase their safety and independence before returning home

(Middleton et al., 2018). Providing education on managing the patient’s chronic conditions and

signs of infection to increase their ability to successfully manage their health at home so they do

not return to the hospital is an additional recommendation (Middleton et al., 2018).

Other strategies focus on improving the quality of care at the SNF. One way to do this is

by implementing a SNF readmission review process (Mendu et al., 2018). This would allow the

SNF to determine what caused the patient to be rehospitalized and figure out what they could

have done differently to prevent it. Then, the SNF would be able to learn from those situations

and make changes to prevent similar readmissions in the future. The SNF should also review

their quality ratings and find ways to improve them as well as improve their infection control

procedures to prevent patients from experiencing a health decline while at the SNF (Yoo et al.,

2015).


Targeting the logistics of patient care such as communication and care coordination has

the potential to decrease readmission rates as well. Improving communication between health

care providers and the patient and their caregivers as well as between acute care facilities and

post-acute care facilities would guarantee that everyone on the patient’s care team understands

the plan of care and the patient’s goals (Mendu et al., 2018; Yoo et al., 2015). Better

communication with the patient and their caregivers would also help the health care professional

gain a better understanding and holistic view of the patient to determine what intrinsic and

extrinsic factors contribute to the patient’s condition so they can tailor the care plan to the

patient. Additionally, when going to a SNF, many patients believe they will be able to stay until

prior level of function is reached, but that is not always the case since insurance companies

determine length of stay. Therefore, improving communication would help the patient

understand what to expect at each level of care and health care providers could address any

questions or concerns they have. It would also be beneficial to improve coordination of care and

information exchange processes between acute and post-acute care facilities (Gupta et al., 2019).

Another solution may be to incorporate transitional care into skilled nursing facilities.

The goal is to prevent poor patient outcomes and increase safety by ensuring the patient has all

the needed resources to successfully transition home (Toles et al., 2017). Overall, researchers

found that “older adults who received transitional care, compared to usual care, were more

prepared and less frequently re-hospitalized after returning home” (Toles et al., 2017, p. 2). This

transitional care model also helps improve the communication between the patient, SNF, and

care providers following the patient after discharge.

Some specific programs have been developed and analyzed to determine if they

effectively reduce readmissions. The Enhanced Care Program was implemented in 8 SNFs and


consisted of 24/7 access to a team of nurse practitioners, medication reviews by pharmacists, and

in-services for SNF staff (Rosen et al., 2018). The researchers found that the program resulted in

29% lower odds of being readmitted to the hospital as well as better coordination between SNF

and hospitals. Another program that has been successful in SNFs is a modified version of

Project ReEngineered Discharge (RED) (Berkowitz et al., 2013). A personalized care plan was

created and reviewed with the patient and their families at admission and discharge, a copy was

provided to the patient and caregiver, and the patient was asked to explain the care plan to ensure

understanding. The staff made follow up appointments for after discharge and made sure patient

got the appropriate durable medical equipment and services after discharge. Education was

provided on the patient’s diagnosis, their medications, including how to take them and where to

get them, and what they should do if a problem arises after discharge. A discharge summary was

also sent to the patient’s primary care provider. Project RED resulted in a significant reduction

in the rate of 30-day rehospitalization from 18.9% to 10.2%. Patients who participated in this

program reported feeling more prepared for discharge and saw their outpatient providers more

frequently (Berkowitz et al., 2013).

Readmissions at Skilled Nursing Facilities

The current research discussed above gives valuable insight into what can be done to

reduce readmissions, but the results are inconsistent and may not be generalizable to all SNFs.

Therefore, this study aims to identify the reasons for readmissions that are specific to this SNF

and use that information to create a solution to reduce patient rehospitalizations, thus decreasing

healthcare costs. Previous research discussed above will be used to inform decisions regarding

this project’s design and implementation. Patient demographics, length of stay, reason for

rehospitalization, and therapy received will be recorded and compared to identify trends in


rehospitalizations. Throughout the process, the site’s leadership, therapists, and Director of

Transitions will be consulted in order to come up with solutions and identify potential barriers.

As previous researchers discussed, it would also be beneficial to interview patients to determine

if they feel prepared for discharge from the SNF, if they feel like their readmission could have

been preventable, and what else could have been done to improve the care they received (Mendu

et al., 2018; Jacobsen et al., 2017). After gathering the data and identifying trends, the goal will

be to come up with a feasible and cost-effective way to reduce the readmission rates based on the

most common reasons for readmission as well as strategies proposed by previous researchers that

may align with this facility’s needs in order to improve quality of care and decrease health care

costs.

Role of Occupational Therapy

A special focus will be put on determining the therapy department’s role in reducing the

readmission rates, particularly occupational therapy. Occupational therapists have a key role in

the prevention of readmission because it is a holistic profession that considers multiple factors

that may contribute to patient success after discharge (American Occupational Therapy

Association, 2017). Additionally, researchers found that “occupational therapy is the only

spending category where additional spending has a statistically significant association with lower

readmission rates” (Rogers et al., 2017, p. 668). This may be because occupational therapy uses

a unique approach to patient care by not only considering the patients’ functional needs, but their

social needs as well, both of which contribute to readmissions (Rogers et al., 2017). Patients are

often unable to engage in their desired occupations and properly care for themselves after

discharge which can decrease quality of life and contribute to a decline in the patient’s condition.

Therefore, occupational therapy can work with the patient to ensure that their physical


limitations as well as psychosocial factors are addressed and considered when deciding what

kind of supports the patient will need at home. When exploring potential solutions to reduce

readmissions, the therapists will be consulted to determine what can be done to maximize

patients’ functional mobility, independence with self-care tasks, and how to improve education

on managing their health and comorbidities as well as organizing follow up care (Middleton et

al., 2018). Being more thorough before discharge will hopefully increase their ability to

successfully manage their condition at home and reduce the number of readmissions.

Gap Analysis

Much has been learned about possible causes of hospital readmission, but results are

inconsistent, and the role of therapy services remains poorly understood. Therefore, the purpose

of this project was to identify common causes for readmission and use that information to

develop recommendations that will help the facility better prepare the patients for

discharge. The overall goal will be to have improved patient outcomes and decreased

readmission rates which will lead to decreased health care spending.

Guiding Model

The Person Environment Occupation Performance (PEOP) model supported this project

well because of its client-centeredness and emphasis on occupational performance. It uses a

biopsychosocial approach which gives more holistic view of the patient and what contextual

factors will affect their ability to participate in desired occupations (Baum et al., 2015).

According to the PEOP model, intrinsic or personal factors include physiological, psychological,

cognitive, neurobehavioral, and spiritual factors and extrinsic or environmental factors are

cultural, social, natural environment, built environment, and societal factors (Baum et al., 2005).

In order for a client to be successful, there needs to be a positive relationship between the person


and their environment (Baum et al., 2015). This positive relationship is achieved when there is a

balance between the client’s intrinsic and extrinsic supports and barriers that allows them to be

functional in their environment.

When applying the PEOP model to this project, it is clear that there is an imbalance

between the supports and barriers for this population. There is something, whether it is intrinsic

or extrinsic, that is preventing them from achieving successful occupational performance in their

home environment which then causes them to be readmitted. Therefore, this project aims to

determine how the rehospitalizations affect patients’ occupational performance and how to better

prepare them thrive in their home environment after discharge to prevent rehospitalizations. In

order to do this, this model was used to determine what potential factors may be contributing to

patient rehospitalizations in order to decide what data to collect. It was important to include both

the intrinsic and extrinsic factors that could be affecting the patients’ success at the SNF and after

discharge in order to align with the holistic PEOP model. Therefore, recommendations and

resources were developed at the conclusion of this study in order to maximize the patients’ time

at the SNF and prepare them to overcome barriers in their home environment at discharge. The

resources developed had a strong focus on providing patients with the knowledge and resources

needed to promote independence with daily occupations and enable them to successfully manage

their conditions at home. But, in order for these changes to be effective, the client has to be

motivated and included in the process. To do this, patient interviews were conducted to ensure

the recommendations were client-centered and met their needs because the patient is the most

important aspect of this project and needs to be collaborator in their care (Baum et al., 2005).


Project Plan and Process

Project Plan

The plan for this project was to perform a retrospective cohort study by reviewing

previous patients’ discharges and their outcomes. Based on previous research and the needs of

the site, it was determined that the following information would be recorded for each patient:

age, sex, race, payer, hospital length of stay, SNF length of stay, primary physician, involvement

in an accountable care organization, admitting diagnosis, number of comorbidities, presence of

specific comorbidities linked to rehospitalizations, therapy received, assistance required with

self-care and mobility at discharge, cognition, and home health referrals. This data was then

analyzed to determine differences in characteristics of patients who were readmitted to the

hospital compared to those who were not readmitted. The results of this analysis was used to

develop recommendations and resources for the site to better facilitate their ability to prepare

patients for discharge thus preventing readmissions.

The researcher also conducted patient interviews (see Appendix B for questions) in order

to obtain their perspectives on the quality of care they received at the SNF and what could have

been done differently to better prepare them for discharge. In order to obtain therapists’

perspectives, the facility’s physical, occupational, and speech therapists were surveyed to get

their opinions on rehospitalizations and what they believe could improve patient outcomes. See

Appendix C for therapist survey questions. The patient and therapist responses were used in

conjunction with the results from the data analysis to ensure the recommendations and resources

developed meet the needs of the site.

Project Goals

The plan discussed above was developed to achieve the following goals.


Project Goal 1: The researcher will determine common causes of hospital readmissions following

discharge from skilled nursing facilities.

Objective 1: In order to identify characteristics associated with hospital readmissions, the

researcher will collect data on demographics, diagnoses, length of stay, and therapy

received while at the skilled nursing facility prior to discharge.

Objective 2: The researcher will analyze the data collected on in order to identify trends

and possible contributing factors to hospital readmission.

Project Goal 2: The researcher will compare the trends in readmission data specific to this site to

relevant published data in order to determine if the trends are consistent with previous research.

Objective 1: The researcher will compile relevant research on causes of hospital

readmissions and analyze their findings to compare to my data.

Objective 2: The researcher will use the findings and trends identified in previous

research studies to inform the decision on what data to collect for this study.

Project Goal 3: At the end of the project, the researcher will utilize the results to provide

recommendations to the SNF aimed at reducing readmissions in order to improve patient

outcomes and reduce healthcare spending.

Objective 1: The researcher will obtain therapist perspectives on the cause, impact, and

preventability of readmissions by creating and implementing a survey.

Objective 2: The researcher will disseminate the results of the literature review and results

of the project in order to provide them with the evidence used to support the

recommendations.


Project Process

In the early stages of the project, the focus was on orienting to the site and finalizing the

plan for the project including what data would be collected for analysis. Meetings were held

with the site mentor and key stakeholders in order to get more detailed information about current

procedures and areas in need of improvement. The project plan was updated and reviewed to

ensure all members of the team understood and agreed with the direction of the project. The

researcher was trained on navigating the electronic medical record (EMR) systems that would be

used for data collection throughout the project. The data was collected and coded in order to

prepare for statistical analysis. The researcher met with a faculty advisor who specializes in

statistics to discuss the data that was collected and ensure proper SPSS tests were run to analyze

the data. Descriptive statistics were run in order to get general information about the sample. An

independent samples t-test was done to compare the mean age, hospital length of stay, SNF

length of stay, number of risk factors, number of comorbidities, and self-care and mobility assist

level between the two groups, patients readmitted to the hospital after discharge and patient who

were not readmitted to the hospital after discharge. For the purpose of this study, risk factors

include chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD),

congestive heart failure (CHF), and diabetes as these conditions were identified by previous

research as correlated with increased risk for readmissions. A binary logistic regression analysis

was also done using the complete data set in order to determine if any of the variables predict a

readmission. A follow up meeting with faculty advisors was held to discuss results.

As current patients discharged from the facility, pre-discharge patient interviews were

conducted. Interviews continued through the end of March in order to obtain a sufficient number

of responses for analysis. At midterm, a formal meeting was held with the site mentor to discuss


progress and establish a plan for the remainder of the project. At the midterm meeting, the

therapist survey was finalized and sent out via email. Once patient interviews were completed

and results were obtained from the therapist survey, results were compiled with the retrospective

data analysis results in order to have a comprehensive data set to inform decisions regarding

solutions and program development. The results were used to update the discharge procedures.

Therapy specific discharge instructions were created along with patient education resources that

will be provided to the patients at discharge to improve carry over of care and increase the

patient’s confidence with their ability to successfully manage their health at home.

The final phase of the project was educating the therapy staff on the overall results of the

project and orienting them to the updated discharge procedures and resources. An overview of

the project was provided to the therapy supervisor so the results could be shared with the

administrator of the facility and other departments to be used to inform future decisions to

improve care at the facility. At the conclusion of the project, a meeting was held with the site

mentor to debrief and complete student and site evaluations. A timeline of the project can be

found in Appendix D.

Project Implementation

Retrospective Cohort Study

This project was submitted to the Indiana University Institutional Review Board (IRB) to

ensure the methods were ethical. It was determined that project did not require an IRB review.

The participants for the main portion of this project were patients who had a skilled stay at the

SNF and were discharged between January 1, 2020 and December 31, 2020. There were 241

patients who met this inclusion criteria and were therefore included in the study. The average

age of patients was 74.69 years (SD = 12.37). The sample was 63.9% female and 85.9% White,


Non-Hispanic. The data were obtained by reviewing the patients’ medical records using 3

different EMR systems. For each patient, the following variables were recorded: age, sex, race,

payer, hospital length of stay, SNF length of stay, primary physician, involvement in an

accountable care organization, admitting diagnosis, number of comorbidities, presence of

specific comorbidities linked to rehospitalizations, therapy received, assistance required with

self-care and mobility at discharge, cognition, and home health referrals. The original plan was

to record any hospitalization within 30 days and 60 days of discharge; however, the research

team was unable to obtain access to the necessary data. Therefore, for the purposes of this study,

the only readmissions that were recorded were those of patients who readmitted to the hospital

directly from the SNF or patients who readmitted to a local hospital network after returning

home. After coding the data, the researcher used SPSS to perform statistical analysis of the data

set.

In order to analyze characteristics of patients who were readmitted to the hospital within

30 days of discharge compared to those who were not, an independent samples t-test was

performed to compare the mean age, hospital length of stay, SNF length of stay, number of risk

factors, number of comorbidities, and self-care and mobility assist level between the two groups.

The independent samples t-test was repeated using 60-day readmission as the grouping variable.

A binary logistic regression analysis was also performed to determine if the variables of interest

predict a readmission. Whether or not the patient experienced a readmission in 30 days was used

as the dependent variable and age, sex, race, payer, hospital length of stay, SNF length of stay,

primary physician, involvement in an accountable care organization, admitting diagnosis,

number of comorbidities, presence of specific comorbidities linked to rehospitalizations, therapy

received, assistance required with self-care and mobility at discharge, cognition, and home health


referrals were the covariates. The binary logistic regression analysis was then repeated using 60-

day readmission as the dependent variable.

Results of Data Analysis

The results of the 30-day readmission t-test are shown in Table 1. There was a significant

difference between average SNF length of stay of patients who were readmitted in 30 days and

those who were not with patients who had shorter length of stays being more likely to readmit,

t(239) = 7.48, p < 0.05. There was also a significant difference in number of comorbidities

between patients who experienced a readmission in 30 days, t(239) = -1.991, p < 0.05. Patients

with more comorbidities were more likely to readmit. The average scores for self-care, t(230) =

4.584, p < 0.05, and mobility, t(228) = 5.884, p < 0.05, were significantly different when looking

at 30-day readmissions. Patients who required more assistance with self-care and mobility tasks

were more likely to readmit.

Patients who readmitted in 60 days also had a statistically significant average SNF length

of stay, t(239) = 3.736, p < 0.05 with shorter length of stays being associated with readmission.

There was a significant difference between number of risk factors present for patients who were

readmitted in 60 days compared to those were not, t(239) = -2.113, p < 0.05. The risk factors

included CAD, CHF, COPD, and diabetes. Patients with more risk factors were more likely to

readmit. There was also a significant difference in number of comorbidities between patients

who experienced a readmission in 60 days, t(239) = -4.931, p < 0.05. Patients with more

comorbidities were more likely to readmit. The average scores for self-care, t(230) = 5.087, p <

0.050, and mobility, t(228) = 5.586, were significantly different when analyzing 60-day

readmissions as well. Patients who required more assistance with self-care and mobility tasks


were more likely to readmit within 60 days. See Table 2 for a summary of the t-test results for

60-day readmissions.

The results of the binary logistic regression analysis for 30-day readmissions are shown

in Table 3 and for 60-day readmission in Table 4. The following variables predicted a

readmission in 30 days – short SNF length of stay, primary physician, diagnosis of CHF, higher

number of comorbidities, and not receiving speech therapy, Chi2 (20) = 55.97. It is important to

note that SNF length of stay is so powerful that when condensing the model for 30-day

readmissions, it made all other variables non-significant. The variables that were found to

predict a readmission in 60 days were diagnoses of diabetes, higher number of comorbidities,

primary physician, and no home heath referral at discharge, Chi2 (20) = 36.81.



Patient Interviews

Participants for the pre-discharge patient interviews were skilled patients who were

currently at the skilled nursing facility with a scheduled discharge date in February and March

2021. There were 27 patients who participated in the pre-discharge interviews. The interviews

were conducted in the patients’ rooms with only the researcher and patient present to ensure

responses and participation were confidential and anonymous. The researcher explained the

nature of the study and obtained verbal consent for participation. The responses were recorded

and coded to identify common themes.

Patient Interview Results

In order to determine what supports the patient would have after discharge, the doctoral

capstone student asked about assistance and equipment available at discharge. The majority of

patients (70%) reported they would be living with family or friends who will be able to assist

them when needed. All of the patients surveyed reported having a home health therapy

evaluation scheduled. Additionally, all of the participants either had the equipment they would

need, or social services was in the process of helping them get it. The patients’ most common

concerns for returning home were not being able to do activities of daily living (ADLs) and

instrumental activities of daily living (IADLs) due to decreased strength, endurance, and

functional mobility. Almost all of the patients also reported general anxiety regarding going

home due to fear of being a burden, depending on others, being lonely, not having the help they

need, and fear of falling. Most patients reported feeling ready to return home (81%), but 78%

were not at their prior level of function.

Since quality of care at the SNF was previously found to be a possible contributing factor

to readmissions, patient satisfaction was measured using a 5-point Likert scale with 1 being very


unsatisfied and 5 being very satisfied (Jacobsen et al., 2017). For overall satisfaction, 52% of

participants reported being very satisfied or satisfied with the care they received at the SNF, but

the most common feedback was that patients are not a priority, and the facility is too understaffed

to provide adequate care. The therapy department received the best ratings with 96% of patients

reporting satisfied or very satisfied. The specific feedback regarding therapy was that the

patients needed more therapy during their stay. The patient’s reported satisfaction of nursing

care was 41% very satisfied or satisfied. The most common feedback was poor communication,

poor call light response and poor care in general (i.e., patients not receiving showers or getting

briefs changed, wound dressings not being changed, nobody checking on patients, etc.). In

regard to satisfaction with social services, 40% of patients reporting they were satisfied or very

satisfied. The need for better communication was the most common response from patients.

When asked what went well during their SNF stay, 48% of people reported therapy. On the other

hand, when asked what could have been done differently, patients stated better communication

from nursing and social services, better care overall from nursing, and more therapy.

Therapist Survey

The participants for the therapist survey were physical, occupational, and speech

therapists currently working at the skilled nursing facility to determine their opinions on

rehospitalizations and ways to reduce them. There were 7 therapists who completed the survey.

The survey was created using Qualtrics and delivered via email to the therapists. Informed

consent was presented at the beginning of the survey and participants had the option to

discontinue the survey at any time.


Therapist Survey Results

There were 57.17% of therapists who agreed that readmission rates are a problem at the

SNF. However, the majority of therapists (71.43%) did not believe readmissions are typically

preventable. Of the therapists who participated in the survey, 57.14% report not having adequate

time to treat patients before discharge, but 71.43% believe they have adequate resources to treat

patients. The participants believed the most common reason patients readmit to the hospital is

that patients are discharged from the SNF before they are ready due to insurance cuts. Other

common responses were poor patient compliance, poor caregiver support, and lack of resources

which make it difficult to manage their conditions at home. The therapists believed the facility

could help prevent readmission but beginning discharge planning early, providing families with

education and resources, and following up with patients after they discharge. In their opinion,

therapy staff specifically could help reduce readmission by doing more family training,

education, and providing resources to enable the patient to safely transition home. When asked

what resources would be most beneficial, the therapists reported information on fall prevention,

energy conservation, local community resources, chronic disease management, and adaptive

equipment.

Recommendation and Resource Development

After compiling all the data, the results were analyzed in order to develop

recommendations that would best meet the needs of the facility. It is important to identify

patients who are at risk for readmissions as early as possible. Since patients with more

comorbidities were more likely to readmit, this would be a way for therapists to identify at risk

patients when they are first admitted. Therapists look at the patients’ list of diagnoses during

their evaluation, so this is an opportunity for them to recognize and address the patient’s needs


from the start of therapy. Therapists can also utilize that time to identify if the patient has any of

the diagnoses that are associated with readmissions such as CAD, CHF, COPD, and diabetes.

Knowing this from the start of treatment will allow the therapist to have adequate time to

compile resources and educate the patients and their caregivers on managing the conditions at

home.

Another recommendation was to improve communication between the healthcare

providers and the patients and their caregivers. In order to facilitate communication between

patients and therapists, a therapy specific discharge instructions document was developed (see

Appendix E). The facility currently gives patients discharge instructions, however, the

information provided is vague and there is not a strong focus on the role of therapy and the

patients’ needs. The goal of the new discharge document is to clearly communicate the patient’s

needs and abilities at discharge in order to ensure the patient’s caregivers know what to expect

and how best to help the patient at home. Since the patients are being discharged before prior

level of function is reached and decreased independence with self-care and mobility is associated

with readmissions, the facility needs to better prepare them and their caregivers for their new

level of care. For the facility as a whole, a way to improve communication is to include patients

in their care plan meetings. Having all members of the care team present along with the patient

and their family will ensure everyone understands the plan and can help the patient be successful.

The SNF length of stay was found to be a predictor of readmissions, but unfortunately it

is unlikely that the therapists will be able to increase the patient’s length of stay as that this

typically determined by insurance companies. However, these results show the importance of

maximizing the time with patients while they are in the facility and providing them with tools to

continue making improvements after discharge. In order to do this, patient education handouts


were developed and compiled so that therapists would have easy access to resources to provide

to patients. The topics for the educational materials were determined based on the results of the

statistical analyses as well as requests from the therapists. Physical copies of the handouts were

filed in the therapy office and put on a flash drive so the therapists would have easy access to the

materials. The topics covered by the handouts were adaptive equipment, durable medical

equipment, aging in place, chronic disease management (COPD, CHF, Diabetes, etc.),

community resources, dementia, driving, energy conservation, fall prevention, general exercise,

upper extremity conditions, joint replacements, home exercise programs, low vision, mental

health, stroke, and technology. Sample educational handouts can be seen in Appendix F. These

handouts can help reduce anxiety and increase confidence for managing health and continuing to

improve functional independence at home thus reducing risk for readmission. Since most

patients return home with help from caregivers, the handouts will be another way to improve

communication between the healthcare providers and the caregivers.

The final recommendation was for the therapy department to advocate for the patients

during their stay in the SNF. It is clear that there is good rapport between the therapists and

patients and the therapist have a good understanding of the patients’ needs, so they are in a good

position to educate other disciplines and advocate for improved care. To facilitate this, the

results of this study will be shared with the facility’s administrator and the leaders in other

departments such as nursing and social services. This will allow the facility as a whole to work

together to improve care and patient outcomes.

At the end of the project, the researcher met with the site mentor to go over results and

educate on resources developed and recommendations to ensure satisfaction and make changes

prior to presenting the information to the therapy staff. After the project was approved by the


site mentor, an in service was held for therapy staff to review results and provide them with the

resources developed. Within the SNF setting, therapists typically have high productivity

standards, so the goal was to disseminate the results in a clear and effective way while also being

mindful of their time. At the end of the presentation, the therapists were able to ask questions

and have an open discussion about the project. A formal project evaluation was done to

determine the effectiveness of the project, but based on the discussion following the presentation,

therapists were receptive to the information and willing to implement the recommendations.

Project Evaluation

Since the primary focus of the project was gathering and reporting information, the

project evaluation focused on determining if the information provided was useful and how likely

the therapists would be to utilize the resources in practice. In order to do this, a survey was

developed to assess the therapists’ satisfaction of the information provided and perceived

feasibility of the proposed changes (See Appendix G). A barrier for program evaluation for this

site was time. This setting has high productivity standards so it was important to keep the

method of evaluation as quick and easy as possible to ensure the therapists would have time to

complete it. Therefore, Likert scales were used for most of the questions and only one open

response question was included on the evaluation. The survey was distributed after the in service

in order to maximize the number of responses. The evaluation was anonymous and the researcher

left the room while the evaluations were completed in order to ensure the therapists felt

comfortable giving honest feedback. The quantitative responses were analyzed by determining

frequency of each response and the qualitative responses were coded to identify themes.


Results

There were 8 participants who responded to the evaluation survey. Using a 5-point Likert

scale with 1 being very unsatisfied and 5 being very satisfied, 25% of respondents reported being

satisfied and 75% reported being very satisfied with the information presented. The remaining

Likert scale questions used a 5-point scale as well with 1 being strongly disagree and 5 being

strongly agree. All of the therapists strongly agreed that the presentation increased their

knowledge of readmissions at the facility. There were 37.5% who agreed and 62.5% who

strongly agreed that the results of this project will benefit the facility and patient care. In regard

to the feasibility of the proposed changes (i.e., discharge instructions and educational handouts),

50% agreed and 37.5% strongly agreed that these were feasible recommendations and the

remaining 12.5% were neutral. When asked if they plan to use the discharge instructions and

educational handouts in practice, 37.5% of therapists agreed and 62.5% strongly agreed.

The final question of the project evaluation asked about perceived barriers to

implementing these changes to provide to the therapy supervisor, so they are able to come up

with a plan to overcome the barriers to ensure sustainability. The most common barrier

identified was making sure the caregivers receive the information without it being left in the

patient’s room, thrown away, etc. Another common response was the therapists time and current

habits. One concern was abrupt discharges or insurance cuts where the therapist doesn’t get to

see the patient again after being notified of the discharge. However, the therapy supervisor plans

to stress the importance of planning for discharge and beginning education from the first day of

therapy to minimize the risk of patients being discharged without resources.


Discussion

Overall, this project brought attention to the readmission problem at this SNF and helped

them identify areas for improvement to provide better quality of care for their patients. The

healthcare professionals at this site were aware that readmissions are a problem but did not

understand the extent of the issue or their role in reducing the readmissions. The problem this

project addressed was that insurance companies mandate the length of stay, so patients are being

discharged before they have fully recovered which is contributing to high hospital readmission

rates. This was confirmed by the data analysis which showed that there was a significant

difference between the average SNF length of stay of patients who experience a readmission

within 30 or 60 days and those who do not with patients with shorter length of stays being more

likely to readmit.

To address the gap between how much time therapists are able to spend with patients

before insurance cuts and how much time is actually needed to regain functional independence,

improvements were made to the discharge process to better prepare the patients to return home.

Ideally, the facility would increase the length of stay for patients, so they are not discharged until

they are ready, but unfortunately this is not a realistic solution. Instead, this project put a focus

on maximizing the time they do have with patients by improving communication, providing

patients with education and resources, and using therapy discharge instructions to ensure carry

over of care at discharge. There was also a gap in the staff’s knowledge of readmission and what

could be done to prevent them which was addressed by the in service and resources provided at

the conclusion of this project.

The researcher was able to achieve all of the goals and objectives set at the beginning of

this project. Common causes of hospital readmissions for this SNF were identified. Similar to


previous research, higher number of comorbidities, decreased independence with self-care and

mobility tasks, and specific chronic conditions such as CHF and diabetes were all associated

with a higher risk of readmitting to the hospital following SNF discharge (Chandra et al., 2019;

Middleton et al., 2018; Neuman et al., 2014). The results were used to develop

recommendations for therapy staff to decrease the patients’ risk of readmitting. It was

determined that improved communication, better discharge planning, and more patient and

caregiver education were necessary to prepare the patients for successful discharge which is

similar to suggestions made by previous researchers (Berkowitz et al., 2013; Mendu et al., 2018;

Middleton et al., 2018).

The patient interviews included in this study gave invaluable insight into the quality of

care being provided at this SNF, but more research needs to be done to determine if these factors

are associated with readmissions as found in previous studies (Jacobsen et al., 2017). To do this,

it would be important to replicate the study at multiple facilities in order to compare their quality

ratings to their readmission rates. Additionally, previous research found the patients race to be

associated with readmission, but this study found no association (Neuman et al., 2014; Yoo et al.,

2015). However, since the population in this study was 85.9% White, Non-Hispanic, this sample

was not diverse enough to get accurate results for that relationship, so more research is needed.

A major limitation of the study was not having access to the necessary records. Ideally,

the research team would have been able to track all readmissions, regardless of the hospital, in

order to obtain more accurate results. However, given the time and resources available, it was

necessary to limit to readmissions to one hospital network. Another notable limitation was time.

It would have been beneficial to have enough time to implement the recommendations in order

to determine the effectiveness. Finally, this project had limited collaboration with other


departments. In order to truly make a difference in readmission rates, there would need to be

participation by the entire facility because therapy alone cannot solve all of the problems.

Interprofessional collaboration is the key to high quality patient care. Future research should

include other disciplines in order to implement facility wide changes such as more specific

transitional care models that have been found to be successful by previous researchers

(Berkowitz et al., 2013; Rosen et al., 2018; Toles et al., 2017). It would be beneficial to look

more specifically at the role of home health services. According to the patient surveys, all of the

patients who were being discharged from the SNF had a referral for a home health evaluation.

While this is a good first step, they are still experiencing readmissions at high numbers so further

research needs to be done to determine where the gap is. One potential problem may be a need

for better communication and transitions from SNF to home health therapy.

Impact

This project had a positive impact on many different levels. For the SNF, this project

helped educate the staff on readmissions and their facility and provided them with tools to better

serve their patients. The patient interviews also helped them understand patient opinions on the

quality of care at the SNF so they can identify areas for improvement. Hopefully, this project

will lead to better quality of care and improved outcomes for future patients at this SNF. For the

occupational therapy profession specifically, the results of this project help to reinforce the value

of therapy in improving patient outcomes since decreased independence with self-care tasks was

associated with higher readmission rates. On a broader level, the results of this project

contribute to current literature on readmissions and may assist future researchers as they continue

to work towards finding an effective solution for reducing readmissions. On a more individual

level, the researcher gained invaluable confidence and advocacy skills. Throughout the project,


the researcher advocated for better patient care by finding the areas that are lacking and

educating staff on ways to improve them. Overall, the project received positive feedback, so the

researcher is optimistic that the site will implement the recommendations and continue to strive

to reduce readmissions.

Sustainability

The therapy supervisor and therapy team were educated on the findings and

recommendations of the study. The therapy supervisor will be sharing the results with the

facility’s administrator and leaders in other departments such as nursing and social services in

order to improve carry over throughout the facility. The recommendations and handouts were

formed using the therapists’ input from the survey in order to increase their likelihood of

utilizing the resources. Additionally, the therapists’ high productivity standards were considered

when developing the recommendations to ensure they would be able to utilize the new discharge

process without creating extra work. For example, all of the therapists are already required to

include a patient education goal in their treatment plan, so instead of doing the same home

exercise program or fall prevention goal that they usually put for every patient, they can tailor

that goal to what educational materials the patient actually needs and utilize the handouts that

have already been developed. The patient education handouts and discharge instructions for the

therapists to utilize at discharge were printed and filed in a centralized location so all of the

therapists can quickly and easily find what they need. All of the resources have also been put on

a flash drive for those who prefer electronic access. The therapy supervisor plans to ensure the

changes are implemented after the researcher is off site and monitor if the recommendations are

beneficial.


Conclusion

Hospital readmissions are a significant problem because they lead to increased healthcare

spending and have a negative effect on the patients. This project aimed to identify common

causes for readmissions and provide recommendations to the skilled nursing facility that would

enable the therapists to better prepare patients for discharge and improve their ability to manage

their conditions at home. Using data from previous discharges, patient interviews, and therapist

surveys, the researcher was able to identify variables that were associated with an increased

likelihood of patients being readmitted to the hospital. Patients with short SNF length of stay,

higher number of comorbidities, and decreased independence with self-care and mobility were

more likely to readmit in 30 days. Patients with shorter SNF length of stay, more comorbidities,

decreased independence with self-care and mobility, and presence of more chronic disease risk

factors such as CHF, CAD, COPD, and diabetes were more likely to readmit within 60 days of

discharge. Binary logistic regression analyses showed short SNF length of stay, primary

physician, presence of CHF, higher number comorbidities, and not receiving speech therapy

predicted a readmission in 30 days. Similarly, diabetes, higher number of comorbidities, primary

physician, and not receiving a home health referral predicted readmissions in 60 days. Based on

the results of this study, improved discharge procedures and patient education materials were

developed. Staff was educated on the importance of advocating for better care for patients and

improving communication between healthcare professionals and the patients and caregivers.

Implementing these changes will enable the SNF to provide better care for patients thus

decreasing readmissions and reducing healthcare costs. While there are some consistencies with

previous research, more studies need to be done to understand what causes readmissions and the

most effective way to prevent them.


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Appendix A

Needs Assessment Interview Questions

1. What are the most common conditions/diagnoses of your residents?

2. When looking at the organization as a whole, are there any goals you are working

towards now?

3. Do you have any projects in mind? Are there any specific areas/facilities that could use

some extra help at this time?

4. What population will I be working with?

a. Would you like me to look into records to get information, follow current

patients, or a mixture?

b. Have you looked at data to see if any of your locations have a higher rate of re-

hospitalization, or is it fairly equal across the board?

5. Do you have a contact person from the home health agency who I could discuss my

project with and/or potentially shadow?

6. Are there any other home health agencies you would like me to collaborate with?

7. Can you tell me more about the Director of Transitions position?

a. What are their roles/responsibilities?

b. How does this position compare to a case manager?

8. What is the average length of time you get to treat patients before they are discharged?

9. What would my time look like when I am at your facilities in Spring 2021?

a. What location would I be at? Who would I report to?

b. Would I also be working on advanced clinical skills?


10. In your opinion, what do you think the greatest strengths this company has to make this a

successful project and find ways to reduce readmissions? Challenges?

11. Do you know how much it costs when patients are readmitted to hospital? Within certain

time frame?

12. Would you be interested in a survey to determine patients’ perceptions on the care they

receive?

13. In your opinion, what would be the best/most beneficial outcome/output of the

project? Information on reasoning for readmission? Program development (checklist,

education or resources to send home with patients since they are being discharged so

quickly)

14. Do you currently provide patients with resources upon discharge?


Appendix B

Patient Interview Questions Pre-Discharge from SNF

1. After leaving this facility, who will you be living with? Will they be able to help you

with daily tasks when needed?

2. Will you be receiving home health services?

3. Overall, how satisfied are you with the care you received at this facility?

a. 1 – Very Unsatisfied 2 – Unsatisfied 3 – Neutral 4 – Satisfied 5 – Very Satisfied

4. How satisfied are you with the care you received from therapy specifically?


5. How satisfied are you with the care you received from nursing specifically?


6. How satisfied are you with the care you received from social services specifically?


7. Do you feel like you are ready to return home?

8. Are you at your prior level of function?

9. What has gone well during your stay at this facility?

10. What could’ve been done differently to better prepare you for discharge?

11. What concerns do you have or what challenges do you anticipate having when returning

home?

12. Are you going to need any durable medical equipment when you return home?


Appendix C

Therapist Survey

By continuing with this survey, you agree to participate in an evaluation of therapists’

perspectives on readmissions which is part of the doctoral capstone project being conducted by

an Indiana University Occupational Therapy Doctorate (IUOTD) student. Completion of this

survey is voluntary and if you choose not to participate, you can exit this survey at any time. The

anonymous data will be used for program evaluation and development in order to improve

quality of care provided at skilled nursing facilities. This study is being conducted by Morgan

Ekstrom, IU OTD Student, under the supervision of Dr. Annie DeRolf.

PROCEDURES:

If you agree to participate, you will receive a link to the survey. This survey will last

approximately 10 minutes.

RISKS AND BENEFITS

There are no identified risks associated with this project and if for any reason a line of

questioning or topic of discussion causes any discomfort you may exit the survey.

The possible benefits of participating in this survey are increasing understanding of common

causes of hospital readmissions. Further, results may contribute to positive changes to enhance

patient outcomes in the future.

CONFIDENTIALITY

This survey is anonymous. You will not be asked to enter your name or any identifiable

information. No one will be able to identify you or your answers, and no one will know whether

or not you participated in the study.

CONTACTS FOR QUESTIONS OR PROBLEMS


For questions or problems about the survey or project, contact Morgan Ekstrom

at [email protected].

For questions about your rights as a participant or to discuss problems, complaints or concerns

about this educational study, or to obtain information, or offer input, contact the IU Human

Subjects Office at (317) 278-3458 [for Indianapolis] or (812) 856-4242 [for Bloomington]

or (800) 696-2949 [Toll Free US].

VOLUNTARY NATURE OF EVALUATION AND STUDY

Taking part in this study is voluntary. You may choose not to take part or may leave the study at

any time. Leaving the study will not result in any penalty or loss of benefits to which you are

entitled. Your decision whether or not to participate in this study will not affect your current or

future relations with IUOT or Indiana University.

1. Please indicate your agreement with the following statements. (Strongly Disagree,

Disagree, Agree, Strongly Agree)

a. Hospital readmission rates are a problem at this SNF.

b. The majority of hospital readmissions are preventable.

c. I have adequate time to prepare my patients for a safe and successful discharge to

home

d. I have adequate resources to prepare my patients for a safe and successful

discharge to home

2. In your opinion, what causes patients to be readmitted to the hospital following discharge

from this skilled nursing facility?


3. What do you think this facility’s staff could do to prevent hospital readmissions following

discharge?

4. What do you think therapy specifically could do to reduce readmission rates at this

facility?

5. What resources would be beneficial for you to have available in order to prepare your

patients for a successful discharge? (i.e. patient education handouts on chronic disease

management, fall prevention, energy conservation, community resources, etc.)


Appendix D

Timeline of the Capstone Project


Appendix E

Therapy Discharge Instruction Form

Therapy Discharge Instructions

for _________________________________ Date: ________________

The purpose of this document is to review the progress you have made in therapy and discuss

your discharge needs in order to successfully transition home. Share this document with the family,

friends, and other caregivers who will be assisting you during this transition so they know how best to

support you.

Discharge plans:

Home alone with support from:

________________________________________________________

Home with family/ friends:

________________________________________________________

Other:

________________________________________________________

Home Evaluation Safety Score: _______________________________ [ ] NA

Recommendations: Remove Throw Rugs/ Grab Bars/ Ramp

Other:___________________________________________________

Caregiver Training Complete for Successful Transition: [ ] YES

[ ] If no, Reason____________________________ [ ] NA

Recommended Therapy After Discharge:

Physical Therapy/Occupational Therapy/Speech Therapy

Home Health Care

Outpatient

Home Exercise/Education Programs (See attached)

Able to Perform Alone with Written Instructions

Able to Perform with Caregiver Guidance (Cues, Prompts, Coaching)

Needs Caregiver Assistance


Physical Therapy

Bed Mobility: ____________

Transfers: ______________

Walk/Propel: ____________

Distance: ______________

Surfaces: _______________

Occupational Therapy

Toileting: _____________

Dressing: _____________

Bathing: ______________

Grooming: ____________

Other: _______________

Speech Therapy

Dementia Stage: _______

Communication Deficit ______

Device_________________

Altered Diet: ______________

Thickened Liquids: _________

Cognition

Safety Awareness: _______________

Deficit Awareness: _______________

Comments & Tips for being successful at home

________________________________________________________________

________________________________________________________________

________________________________________________________________

Device: Walker/Rollator/Cane/Other

Fall Risk: _____________________________

Stairs/Steps/Ramps: ____________________

Car Transfer: __________________________

Other: ________________________________

Adaptive Equipment

Sock Aid/ Dressing Stick/Reacher

Divided Plate/Plate Guard/Weighted Utensils

Other: ________________________________

IADLs

Cooking

Medication Management

Other: ________________________________

Safe Swallow Strategies

_____________________

______________________

Cognition: ____________________________

_____________________________

Other: ________________________________


Appendix F

Sample Patient Education Documents

REM OV E H A Z A RD S A N D M A K E M OD I FI CA T I ON S

This handout is for educational purposes only. Always follow the advice of your doctor or

health care professionals. Information Retrieved From:

Mayo Foundation for Medical Education and Research. (2019, October 4). Fall prevention: Simple tips to prevent

falls. Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/healthy-aging/in-depth/fall-prevention/art-20047358.

Fa l l Pr even t i o n

U SE L I GH T S

W EA R SA FE SH OES

ST A Y A CT I V E

T A L K T O YOU R D OCT OR

Centers for Disease Control and Prevention. (2017, February 10). Important Facts About Falls.

https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html.

1

MILLIONS OFOLDER ADULTS

FALL EVERY YEAR1

1 OUT OF 5 FALLSRESULT IN SERIOUS

INJURIES 1

OVER 95% OF HIPFRACTURES ARE

CAUSED BY FALLS 1








Appendix G

Capstone Project Evaluation

1. Please rate your overall satisfaction with the information presented.

1 2 3 4 5

Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied

2. The data collected and presented increased my knowledge of readmissions at this facility.

1 2 3 4 5

Strongly Disagree Disagree Neutral Agree Strongly Agree

3. This information discussed will benefit the facility and improve quality of care provided.

1 2 3 4 5


4. The proposed recommendation of providing patients with discharge instructions and

educational materials is a feasible way to improve the discharge process and reduce

readmissions.

1 2 3 4 5


5. I plan to use the discharge instructions and educational handouts.

1 2 3 4 5


6. In your opinion, what are the barriers to utilizing the discharge instructions and

educational handouts?