Care Transitions: Keys to Reducing Post-Discharge Hospital Readmissions

By Caralyn Davis, Staff Writer - April 25, 2019

The Centers for Medicare & Medicaid Services (CMS) is pushing skilled nursing facilities (SNFs) to be accountable for hospital readmissions—even post-discharge from the SNF—via multiple fronts. First and foremost is the claims-based SNF 30-Day All-Cause Readmission Measure (SNFRM). This measure shows the risk-standardized rate of unplanned, all-cause inpatient hospital readmissions of Medicare beneficiaries within 30 days of discharge from a prior hospital stay (i.e., both hospital readmissions within the SNF stay and after discharge).