Readmission Prevention: Solutions Across the Provider Continuum

As a result of the Affordable Care Act (ACA), readmissions have become a new area of focus as care delivery moves from a volume-based model to a value-based one. Acute hospitals are calling upon post-acute providers to assist them in improving care coordination to avoid penalties. Post-acute providers are taking steps to become the provider of choice as hospitals, health systems, and managed care organizations turn to them for support. In the absence of proven historical programs, this book gives hospital executives and post-acute care providers proven tactics and tools they can apply to reduce and prevent unnecessary hospitalizations. Written in a conversational style by a seasoned healthcare executive, the book starts by defining the origins of readmissions and the impact of the ACA, then describes three phases of readmission prevention planning and offers innovative strategies for executives to position their facility as a provider of choice. Specific readmission prevention tactics are addressed for different levels of post-acute care, including:

Acute care hospitals and health systems Skilled nursing facilities Physicians and Pharmacists Long-term acute care and acute rehabilitation hospitals Home health agencies Hospice and palliative care agencies Assisted-living facilities Home care and private-duty nursing

Throughout the book, short perspectives written by experts in the different specialty areas provide additional viewpoints on critical issues in care transitions. The book concludes with case examples from healthcare organizations that have successfully implemented new tactics and strategies as part of a larger coordinated program in preventing readmissions.

Josh D. Luke, PhD, FACHE, is founder of the National Readmission Prevention Collaborative and the National Bundled Payment Collaborative. He is a national thought leader and international speaker on the topics of care coordination, population health management, readmission prevention, and development of integrated post-acute care networks. He is a former hospital CEO, health system vice president, and nursing home administrator. Regarded as a futurist on the Affordable Care Act (ACA) and how it will shape the continuum of care, he has been described as an innovator, a forward thinker, and a strategist on teaching accountable care organizations, bundled-payment initiative programs, and hospital leaders how to position themselves for revenue growth in the transitional care and post-acute care sectors in a post-ACA model.

He currently serves as executive faculty at the University of Southern California, Sol Price School of Public Policy. In 2013, he was named vice president of post-acute services for Torrance Memorial Health System. In that role, he designed a population management strategy (Total Wellness Torrance), working with the ACO, Bundled Payment and IPA teams. Total Wellness Torrance and its Post Acute Network received the 2013 Excellence in Programming award from California Association of Health Facilities. He has a Ph.D. in Educational Leadership, is a Lean Six Sigma Black Belt, and has served as a Lean Mentor.