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Report: N.Y. Hospitals, Nursing Facilities Utilize Innovative Strategies to Reduce Readmissions

ALBANY, N.Y. (May 12, 2014) – New York metropolitan area hospitals and nursing homes are developing innovative strategies to eliminate avoidable hospitalizations and to reduce readmissions, according to a new report from the University at Albany's Center for Health Workforce Studies (CHWS).

The study was conducted with support from, and in collaboration with, the Greater New York Hospital Association and the Continuing Care Leadership Coalition. Health care providers both in the state and around the nation are under increasing pressure to provide high quality, cost-effective health care that can reduce demand for unnecessary and inappropriate services.

UAlbany study finds Hospitals are finding innovative ways to reduce readmissions from Nursing Homes
New York hospitals and long-term care facilities are finding innovative ways to reduce hospital readmissions from nursing homes, according to a new report from CHWS.

"Many hospitals and nursing homes in New York are implementing programs to improve patient transitions from hospitals to post-acute care in nursing homes or in the community," said Jean Moore, director of CHWS, based at UAlbany's School of Public Health. "Health workers in a variety of roles impact these transitions and are critical to achieving positive health outcomes for patients.”

To better understand workforce strategies to improve the effective management of care transitions, CHWS conducted a series of case studies in New York City’s metropolitan region, interviewing administrative and clinical staff at a small number of hospitals and nursing homes. Among the many initiatives to reduce avoidable hospitalizations, hospitals have created new positions or strategically employed existing personnel to improve care transitions between hospitals, nursing homes, and the community.

At the same time, long-term care facilities are training their staff, including direct care workers and support staff to use a “stop and watch” method that focuses on recognizing and reporting sudden changes in residents’ conditions. Both hospitals and nursing homes agree that effective and meaningful information sharing across settings and among health professionals, caretakers, and patients is essential to improving the quality of outcomes from care transitions.

Hospital Workforce Innovations

Some hospitals have designated a clinical professional, such as nurse or physician assistant, as a liaison to nursing homes to enable care coordination across settings during and after transitions. Others have designated clinical liaisons responsible for coordinating care for all patients coming to the emergency department from a nursing home and to help clinicians determine the most appropriate post-acute care disposition for that patient. Hospitals are also designating a single hospitalist physician to act as the clinical contact for all nursing homes with high volume admissions from the hospital to ensure that problems arising during or after patient transitions are quickly resolved. This has improved the timeliness and appropriateness of communications related to patient clinical care across settings, and appears to have contributed to better patient management over the long term.

Nursing Home Workforce Innovations

Based on the quality improvement program INTERACT (Interventions to Reduce Acute Care Transfers), nursing homes are training many of their workers to recognize and report possible changes in a resident’s condition to clinical staff. This triggers a clinical assessment of the patient that can reduce the likelihood that an emerging health condition results in hospitalization.

In some nursing homes, a staff member is designated as an onsite evaluator or nursing home liaison to a hospital for patients in transition to post-acute care. An in-depth evaluation prior to nursing home admission better ensures that a nursing home can furnish the care required to achieve the desired health outcome and to prevent re-hospitalization.

A recently implemented Federal demonstration project (Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents) has enabled 30 nursing homes in New York to have a registered nurse care coordinator (RNCC) in the facility to assist with implementing evidence-based interventions to improve outcomes for long-stay nursing home residents at risk for hospitalization.


The study found that the most effective strategies for improving outcomes of patient transitions from hospitals to nursing homes included:

  • Better information sharing among hospitals, nursing homes, patients, families, and caregivers;
  • Improved communication pathways to clinical providers in hospitals and nursing homes in order to provide essential information during and after patient transitions; and
  • More active involvement of a team of professionals representing administration, social work, clinical, and non-clinical staff in efforts to improve outcomes for patients.

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