Reducing Readmissions: Eliminating the Gaps

A recent article by Forbes Magazine, focused on ways nursing homes can help decrease preventable re-hospitalizations – the ideas range from increasing staff training to help them identify and treat situations that can lead to hospitalizations to very simple practices such as simply asking patients and or families if they want to be sent to the hospital.

decreaseUnnecessary re-hospitalizations cost Medicare millions of dollars every year, and 60% of these are preventable, according to Forbes Magazine. Hospitals, nursing homes and Medicare home health care agencies are just of few of the many providers today focused on preventing re-hospitalizations. This focus is driven by new Medicare rules that began October 1st, 2012 which cut payment to hospitals where too many patients were re-admitted within 30 days of discharge. Many hospitals are putting transitions programs in place and relying on transitional care facilities (nursing homes) or Medicare home health agencies to provide extra oversight and care needed to keep people from re-hospitalizations.

While these programs are a start, unfortunately there are still gaps in these systems that continue to lead to unnecessary re-hospitalizations. Medicare home health, for example, is only for those seniors deemed “homebound,” defined as having difficulty leaving their home for any reason.

In addition, Medicare home health is designed to be a short-term solution for people with acute care needs. That means it is designed to end, not go on for long-term. The national average for Medicare home health visits is 36 – what happens after Medicare home health services end? In 2007 the New England Journal of Medicine did a study of 11 million Medicare recipients and found that 1 in 5 were re-hospitalized in 30 days and 1 in 3 were re-hospitalized in 90 days, regardless of age, diagnosis or participation in Medicare home health programs. In 2011, the Dartmouth Atlas Project found that from 2004 to 2009, despite efforts to reduce readmissions, the 2009 study’s results still stand. According to them, there is still wide room for care crisis

So what is needed to keep all seniors from unnecessary re-hospitalizations? At Lifesprk, we’ve found there are 8 essential elements that close the gaps to prevent unnecessary re-hospitalizations.

These essential factors for success are:

  1. A focus on what the person wants (wishes and needs) – this helps build engagement and ensures that goals are aligned
  2. Proactive guidance – this helps anticipate problems and address little issues before they become major problems
  3. A trusted advisor who can guide people across ALL settings – this ensures continuity and consistency in the individual patient’s goals
  4. Connectivity to reliable resources
  5. Long-term solution to reduce gaps and fragmentation – many of the solutions being implemented to reduce readmissions such as care transitions programs or care management services are time-limited and end after 30 or 60 days. Then what?
  6. A focus on the whole-person across all 7 elements of living well – this prevents a silo solution that just looks at one diagnosis or a single dimension of someone
  7. Meeting people wherever they are
  8. A comprehensive life plan

The efforts taking shape across the health care industry today are making are just starting to make progress in reducing readmissions, and we need to make sure that the services go far enough to eliminate the gaps that can cause readmissions.


Beth Nemec, Director of Sales

At the age of 15, Beth knew she wanted to devote her career to working with people in the second half of life because of the great relationship she had with her Grandma. She has more than 29 years’ experience in the healthcare industry, 25 of those years were spent delivering home health care services. Beth seeks the spark by training others to be passionate about their work ─ she believes when people love what they do it changes the experience for the client. Helping people to age well, on their terms, is what she is most passionate about.

A founder and an early general manager in Lifesprk’s development, Beth has experience in both operational and sales roles and has worked for both skilled/Medicare, hospice, infusion and private duty agencies. In addition to her roles at Lifesprk, Beth lends her insight and guidance to local groups in support of their efforts to care for people as they age. These community committees include the national private duty association and memory care professionals. Beth served as President of the Minneapolis Area Senior Workers Association which has over 250 members. An expert in the Twin Cities long-term care industry, Beth feels serving seniors is a rewarding experience and a responsibility she takes very seriously.

Prior to joining Lifesprk, Beth was the Twin Cities General Manager for AdvoLife, Inc., a home care and senior service company based in San Jose, California where she led the company’s expansion, establishing them as a market leader with over $3 million in annual revenue. Beth has a BS in Health Care Administration from UW-Eau Claire.

For more information about Lifesprk, call Lifesprk Navigation at 952-345-8770, email us or visit