On-Demand Webinar: The Safety Net - Catch Readmission Risks Before They Escalate-The Safety Net - Catch Readmission Risks Before They Escalate

Video Transcription

Video Summary

The webinar, led by Lauren Stenson from APACEN, focuses on preventing hospital readmissions among long-term and post-acute care residents. Hospital readmissions pose significant clinical, financial, and regulatory challenges, especially for frail residents with complex medical conditions. Key causes include infections (UTIs, pneumonia), cardiopulmonary issues (CHF, COPD), medication complications, and falls, often exacerbated by psychosocial factors like depression and inadequate family support.<br /><br />Evidence-based strategies emphasize early detection of clinical changes through standardized assessment tools such as INTERACT, SBAR communication, and the Stop and Watch checklist, fostering timely intervention to avoid escalation. Strong interdisciplinary teamwork among nurses, therapists, pharmacists, dietitians, social workers, and activity staff underpins effective prevention, with each discipline playing targeted roles—from proactive mobility support and medication optimization to social and emotional care.<br /><br />Leadership is critical in creating a culture of safety, coaching staff, coordinating interdisciplinary efforts, and integrating readmission prevention into quality assurance programs and hospital partnerships. Effective transitions of care, family engagement, advanced care planning, and infection control protocols further reduce readmission risks.<br /><br />A case study illustrated applying these principles to manage a recently hospitalized resident at risk of relapse, highlighting the value of coordinated assessment, communication, and on-site management.<br /><br />Attendees are encouraged to develop actionable, measurable plans with shared accountability to improve outcomes and reduce unnecessary rehospitalizations. Overall, combining tools, teamwork, and leadership fosters safer, more stable care environments where avoidable hospital transfers become exceptions rather than norms.

Keywords

hospital readmissions

long-term care

post-acute care

INTERACT assessment tools

SBAR communication

infection control

interdisciplinary teamwork

leadership in healthcare

care transitions

preventing rehospitalization