Reducing Readmissions After Admission to IRF: Differentiating IRF from Other Post-Acute Care Settings-Reducing Readmissions After Admission to IRF: Differentiating IRF from Other Post-Acute Care Settings

Reducing Readmissions After Admission to IRF: Differentiating IRF from Other Post-Acute Care Settings

Video Transcription

Video Summary

Dr. Lisa Charbonneau and Dr. Alberto Eskenazi, along with Dr. Joseph Stillo, discussed the topic of reducing transfers to acute care after admission to inpatient rehabilitation. They highlighted the importance of this metric and the challenges associated with it. They discussed the high rate of unplanned transfers out of rehabilitation and the negative impact it has on patients. They also mentioned how reducing transfers is a high priority in healthcare reform and is measured by programs such as Medicare ACOs, Medicaid, and IRFs. They discussed the various predictors of unplanned transfers, including age, complexity of medical needs, cardiovascular and respiratory conditions, and reduced functional status. They also mentioned modifiable factors that contribute to readmissions, such as premature discharge, unresolved clinical issues, and medication errors. The speakers shared their experiences and strategies for reducing transfers at their facilities, including the use of early warning systems, video robot interactions, and monthly reviews of transfer rates. They emphasized the importance of communication and collaboration with acute care hospitals to improve care transitions and reduce readmissions. Finally, they discussed the development of the REACT algorithm, which is a predictive model for acute care transfer risk. They shared how this algorithm is integrated into their electronic medical record system and how it helps identify at-risk patients and support clinical decision-making. Overall, the speakers highlighted the need for proactive measures and continuous improvement to reduce transfers to acute care after admission to inpatient rehabilitation.

Keywords

reducing transfers

acute care

inpatient rehabilitation

unplanned transfers

healthcare reform

predictors of unplanned transfers

readmissions

communication

REACT algorithm