Clinical Risk Considerations for New Residents Reducing Hospital Re-Admissions


As a result of the CMS initiative to reduce hospital re-admissions, nursing facilities are focusing on providing solutions for avoidable re-hospitalizations and positioning themselves as valuable post-acute care partners. We understand that hospitalizations are expensive and disorienting for our frail elderly population. Our residents are especially vulnerable to the risks that accompany hospital stays and transitions between nursing facilities and hospitals, including medication errors and hospital-acquired infections.

It is important to evaluate the risk factors upon admission in order to strengthen your facility’s clinical risk program. This is especially true for a new resident. Chances are that they were treated in the hospital by a hospitalist and not their primary care physician. The physician that sees the resident in your facility may also be new to them, resulting in the resident having a new health care team. This is before we factor in the related trauma statistics which increase per transfer (e.g., from home to emergency room, to one or two hospital rooms based on condition, then to your facility.) This is in addition to surgical procedures, anesthesia, pain, and any existing conditions such as cognitive loss, anxiety, sensory deficits, etc., resulting in:

  • transfer trauma
  • fear and anxiety
  • further de-stabilization of medical, psychosocial, and psychological well-being.

A more in-depth look at transfer issues would note that often the trauma of the transfer increases confusion and decreases a resident’s mental function. Transfer trauma may cause or worsen existing issues with fear and anxiety. The ultimate results of transfer trauma may be to further de-stabilize medical, psychosocial, and psychological well-being. In addition to transfer trauma, a newly admitted resident may be sick and/or recuperating, therefore, they are already at risk. This can complicate common conditions in the population we serve such as cognition, sensory status, mood, and behavior. Identifying and addressing these areas of risk upon admission to your facility is essential and can help you in your efforts to reduce readmissions to the hospital.

For more information and training, contact TMC regarding our Stability First program at: