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With the 2012 implementation of CMS’s Hospital Readmission Reduction Program, post-acute care organizations have been taking a hard look at what they can do to decrease potentially avoidable hospitalizations, thereby becoming the optimal post-acute care partner. Since the implementation of this program, decreasing avoidable hospitalizations has probably been the number one clinical initiative of many post-acute care organizations. Care coordination and communication between post-acute care organizations and acute care facilities has improved. Physician oversight of patients at risk has increased. Medication reconciliation, patient education, and advanced care planning are occurring more frequently than ever before.
While all of the above changes are necessary to decrease the prevalence of potentially avoidable hospitalizations, post-acute care organizations can do more. It is oftentimes the most fundamental and basic changes that have the largest impact on the quality of patient care. So what is this fundamental and basic change? It is taking a clinical approach to preventing potentially avoidable hospitalizations by providing effective primary care interventions. Primary care interventions involve two things – prevention and assessment. This whitepaper demonstrates how to apply prevention and assessment to the care of patients with conditions included under the Readmission Reduction Program – heart failure, pneumonia, myocardial infarctions, COPD, and total hip and total knee arthroplasty.