Elderly discharged from an observation, or an Emergency Department visit, in the Hospital are likely to return (20%) for a visit or admission. That means, as far as NH’s are concerned, a person post ED or Observation stay, should be closely followed by a clinician to address whatever problems that led to the original dominion or ED visit. Care Transition protocols, spearheaded by Eric Coleman, for community transfers should be tweaked to address the NH process of care. It should include at least a pharmacy review of medications, and an exam by NP/MD within a reasonable time from return to NH (24-72hrs).

As we expand our State wide reach with CALTCM SNF 2.0®, which involves INTERACT and leadership training, we should consider addressing this subpopulation of NH residents and develop approaches for management. The current Title 22 requirements do not require a clinician visit after an ED visit or a hospital stay of less than 72 hours.

Link to article: http://www.healthleadersmedia.com/quality/hospital-revisits-often-follow-observation-stays