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Senior Care in Motion's Foundational Mission: To Reduce Avoidable Readmissions

Hospitalizations account for nearly one-third of the total $2 trillion spent on health care in the United States. In most cases, hospitalization is necessary and appropriate. However, a substantial fraction of all hospitalizations are patients returning to the hospital soon after their previous stay. These rehospitalizations are costly, potentially harmful, and often avoidable. Medicare, Medicaid, and Private Insurances have and will continue to implement reimbursement payment changes for “avoidable” rehospitalizations to the provider. Evidence suggests that the rate of avoidable rehospitalization can be reduced by improving core discharge planning and transition processes out of the hospital; improving transitions and care coordination at the interfaces between care settings; and enhancing coaching, education, and support for patient self-management.[i]

Re-hospitalization is a common occurrence in the first 72 hours, and within 7 days of admission to a lower level of care. The number one reason identified is the lack of collaboration and communication of the patient’s care service and needs between healthcare providers. [ii]

Key Intervention to Deter Unnecessary Rehospitalization: The ADMISSION Process: The FIRST 48

CHN Senior Care in Motion “Transitions in Care Model” has developed the groundwork for this phase in the patient’s transition of care, which is known as The FIRST 48. These steps utilize a team approach to patient-centered care, creating a culture of safety and preparedness. Every member of the care team must be alert to the patient’s arrival and prepare to provide a warm welcome, which will decrease fears and anxiety and foster trusting relationships. The FIRST 48 not only fosters communication and empowerment it is also is based on evidence-based best practices to ensure adherence to facility policy and regulatory requirements. The seven major elements of FIRST 48:

  1. Complete a safe “hand-off” from discharging facility, gathering enough information to ensure continuum of care services and preparation for patient arrival;

  2. Review and disseminate all information obtained during preadmission determination;

  3. Communicate the patient’s needs and risks to appropriate Interdisciplinary Team members and Unit nursing team;

  4. Steps 2 & 3 are critical! These steps prior to a residents’ admission to the Community will assist the facility’s clinical team and care givers to implement plans to “prevent” exacerbation of a chronic condition or implement monitoring to decrease the propensity of an adverse event such as falls, infections, weight loss or behaviors.

  5. Ensure the initial preparation: patient’s room, equipment, safety plans for fall and infection, and identifiers for change in patient condition are in place.

  6. Within 48 hours, all team members will meet and get to know patient, ensuring immediate needs are being addressed and safety measures are implemented to prevent exacerbation of chronic disease(s) or an adverse occurrence event.;

  7. Within 48 hours, the Interdisciplinary Team will meet with patient and/or significant party and discuss initial plan of care, medication reconciliation, discharge planning and community needs.

Increasing your teams’ awareness to the Life Planning Community’s “transitions in care” processes, knowing the resident’s needs and risks prior to and at the time of admission can reduce hospitalizations and lead to improved patient experience and quality services.

If you are in need of assistance to review and improve existing transitions of care processes, do not hesitate to contact Diane at

If you are in need of increasing your clinical teams’ awareness and skills performance in chronic disease management, infection control and other clinical services, do not hesitate to contact Trish Manchester at


[ii] Agency for Healthcare Research and Quality (AHRQ): Reducing Avoidable Hospital Readmissions: Healthcare Intelligence Network November 2014, Volume IV,NO.22; CFR 483.10 Resident Rights. __________________________________________________________________ [1] Institute of Healthcare Improvement: [1] Agency for Healthcare Research and Quality (AHRQ): Reducing Avoidable Hospital Readmissions: Healthcare Intelligence Network November 2014, Volume IV,NO.22; CFR 483.10 Resident Rights.


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