As certified HHAs already know, Medicare is tracking your hospital admission rates. Hospital re-admission rates are tracked for all providers...hospitals, nursing homes, rehabilitation, dialysis facilities... because a hospital admission may suggest a breakdown in patient care.
Around the country, providers feel the pressure of reducing hospital re-admissions because referral sources favor those agencies that have LOW re-admission rates...for obvious reasons.
Diagnosing the reason for a hospital readmission is not difficult: the patient's condition deteriorated to point of needing emergent care. The key to reducing the incidence of the re-admissions is prevention. Below are the reasons for hospital re-admissions...and the remedy.
Reason #1. Physician orders are not working.
In order to prevent hospital admissions the patient’s treatment has to work. 
The Start of Care visit schedule is the KEY TO PREVENTING READMISSION for treatment issues. Skilled visits must be FRONT LOADED to aggressively determine the effectiveness of the new or changed physician careplan.
Solution: Front-load Visits.
If you are writing orders like "SN 1w9" for a Start of care OASIS you are inviting a re-admission.
The first order of business when admitting a patient is to make sure the new or changed physician orders ARE WORKING.
If home health services are ordered the patient most likely has a new or changed treatment plan. Your scheduling policies and procedures should include ‘front-loading’ visits…i.e. scheduling the bulk of skilled visits for the first 1-3 weeks of an episode…to assure the new or changed physician orders are controlling symptoms. The old ‘1w9’ is appropriate for long-term maintenance re-certifications…not admissions or resumptions of care.
Your skilled visit schedules for the first 30 days of a Start of Care should look something like this –
3w1, 2w1, 1w2
It should take no longer than two (2) weeks of a front-loaded visit schedule to determine if physician orders are controlling patient symptoms. In most cases, with the front-loading of visits, effective symptoms control can be determined in the first week.
Reason #2. The patient doesn’t know how to manage symptoms.
Are your patients receiving written instructions on the preventive care for each diagnosis? Are you providing a teaching plan for each of the patient's diagnoses?
And...are you asking for recall when teaching is performed?
If not, how is the patient supposed to remember the symptom management needed to prevent an exacerbation?
Solution: Provide a teaching guide and document the patient's recall.
In addition to monitoring the effectiveness of new/changed treatment, patients/caregivers must be taught the PREVENTIVE CARE needed to MANAGE SYMPTOMS.
In addition to providing a comprehensive teaching guide, the patient should be expected to RECALL the information on regular intervals during the episode.
Reason #3. The patient doesn’t know when to call the doctor.
In most cases there are WARNING SIGNS that the treatment plan needs adjustments. In other words... symptoms are starting to deteriorate. Does your patient receive a written list of these warning signs? Additionally, is the patient able to RECALL these warning signs?
Solution: Provide a symptom list and document the patient's recall.
The patient/caregiver should know when to call the physician before symptoms deteriorate!
Hospital admissions can be avoided if the patient/caregiver are on alert for warning signs. The patient/caregiver should know the signs and symptoms that indicate ineffective treatment – and the need for physician notification before the need to be hospitalized is necessary.
Patient Recall/Teachback. You need to know if the patient/caregiver can identify when symptoms are deteriorating ...after discharge. This is achieved via recall or teachback or demonstration of knowledge and procedures.
In addition to providing a comprehensive teaching guide, the patient should be expected to RECALL the information on regular intervals during the episode.
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