Patient Referral

How to Avoid 30-Day Hospital Readmissions

hospital readmissions

In 2012, the Centers for Medicare and Medicaid Services (CMS) began reducing Medicare payments for hospitals deemed to have excess readmissions for patients within 30 days. While readmission rates have dropped in the past five years, over 2500 hospitals still faced these penalties.

In many cases, readmissions can be avoided with more education and support in the home. Crossroads Hospice & Palliative Care is in a unique position to be able to support patients and their families at any stage of a serious illness and to assist physicians in preventing avoidable hospital readmissions.

Palliative Care Consultations

When hospitals discharge a patient, they are in the unenviable position of sending a patient to an unknown environment. Palliative care is an ideal partner for bridging the gap between home and hospital by providing nurse practitioners and social workers who can visit the home and assess the patient’s individual needs.

Working with the hospital and the patient’s physicians, a plan of care is developed to ensure the patient has the resources they need to stay home with their family.

Hospice Care Support at Home

Two of the conditions that CMS takes a special look at are readmissions for heart failure and COPD. Both are known for breathing difficulties that have families rushing their loved ones to the emergency room for care that could actually be managed at home with the proper support.

Crossroads is available 24 hours a day, 7 days a week, 365 days a year to address concerns and provide care. Families and assisted living facilities are able to call us instead of an ambulance, preventing a visit to the ER or hospital readmission.

How to Refer a Patient to Hospice

Crossroads makes hospice referrals easy, so patients can get the care they need as quickly as possible. Physicians, discharge planners, or family members can refer a patient by calling 1-888-564-3405 or visiting our website referral form. Our team will work with physicians to receive an order for hospice and/or palliative care based on the patient’s needs. We then arrange a convenient time and place to meet with the patient and their family or power of attorney to review and sign consent forms. 

Hospice evaluations and admissions are done the same day, and services can begin immediately.

Once a patient is admitted to service, our hospice care team will ensure they have all the medication, equipment, and supplies needed to provide care in the home. Nurses and aides will make regular visits to provide nursing and personal care. Social workers, chaplains, bereavement coordinators, and volunteers will also work with the patient and their family to ensure their emotional and spiritual needs are being met.

To learn more about how Crossroads can help prevent hospital readmissions, please call us at 1-888-564-3405.


Recommended Reading:

Healthcare Professional Quiz: Is Your Patient Hospice Appropriate?

End-Stage COPD: When is it Time for Hospice?

Heartlink: Your Partner in Managing Congestive Heart Failure at Home


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Copyright © 2017 Crossroads Hospice & Palliative Care. All rights reserved.

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