Hospital readmissions are among the most visible indicators of quality in skilled nursing facilities (SNFs), with significant implications for value-based care, reimbursement and operational reputation. While often viewed as unavoidable, many causes of rehospitalization are predictable and, thankfully, preventable — with timely assessment, structured care planning and strong physician oversight.
Let's explore how pragmatic, research-backed readmission prevention strategies led by physiatrists can turn readmission risks into clinical wins for both SNF residents and your facility.
Common Causes of Rehospitalization in SNFs
Frequent hospital readmissions from skilled nursing facilities are often the result of issues that, with the right systems in place, can be prevented.
Many complications develop gradually over days or weeks, often signaled by small but significant shifts in a resident’s function, mood or clinical status. Unfortunately, these early warning signs may go unnoticed, resulting in the most common rehospitalization culprits, including:
- Poorly controlled pain
- Spasticity
- Infections
- Functional decline
- Falls
- Worsening symptoms
- Clinical deterioration
- Inadequate management of chronic conditions, such as heart failure, chronic obstructive pulmonary disease (COPD) or diabetes
The True Impact of SNF Hospital Readmissions
Readmissions are rarely isolated. These events point to broader gaps across the care continuum. For SNF leaders and teams alike, reducing readmissions is central to demonstrating and delivering high-quality, resident-centered care under value-based care models.
In today’s value-driven healthcare landscape, skilled nursing facilities are evaluated on the measurable outcomes they achieve for residents. This shift means that your center is held increasingly accountable for preventing avoidable adverse events, including unnecessary hospital readmissions.
In this competitive, outcomes-focused system, high readmission rates could negatively impact your SNF in several ways.
Undermining Quality of Care Transitions and Clinical Oversight
High readmission rates often indicate that teams missed a critical step at key transition points, such as when a resident moves from the hospital to your SNF or in the early days after admission. These breakdowns may include:
- Missed details in handoff communication
- Incomplete care plans
- Lack of close monitoring for early warning signs
Impacting Resident Experience and Facility Reputation
Every hospital readmission disrupts a resident’s recovery, causing unnecessary stress and potentially setting back their functional progress. For residents and their families, this cycle can quickly erode trust, not just in individual caregivers, but in the facility as a whole. Over time, a pattern of frequent readmissions may create the perception that an SNF is unable to provide responsive, resident-centered care, impacting the center's reputation within the local healthcare community.
Falling Short of Value-Based Care Expectations
Readmission rates are a key marker in value-based care models. Persistent readmissions may be viewed as a sign that the facility is not meeting the high standards of quality, safety and accountability that modern SNF leaders are expected to achieve.
Attracting Greater Regulatory Scrutiny
The Centers for Medicare & Medicaid Services (CMS) closely monitors readmission rates through initiatives like the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program. High rates can draw unwanted attention from regulators and may prompt more frequent reviews, audits or penalties from oversight agencies.
The Role of Physician Oversight in Preventing SNF Readmissions
Reducing hospital readmissions is more than a matter of chance. It requires vigilant physician oversight to identify risks and create strong interdisciplinary collaboration. While primary care physicians provide essential medical management, consulting physiatrists bring a unique expertise focused on function, mobility and complex medical conditions — key domains that often predict readmission risk.
Medrina's physical medicine and rehabilitation (PM&R) specialists play a vital role in the SNF setting, bridging medical and rehabilitative care. As consulting partners, our experts work alongside your team to spot functional and medical issues early, coordinate care and help keep residents safely on track to prevent hospital readmissions.
Enhancing Early Detection
Consistent physician involvement is a cornerstone of effective readmission prevention. Physiatrists bring a function-focused perspective, using routine assessments to identify early warning signs such as declining endurance, gait instability or a resident’s need for increased assistance — all strong predictors of potential medical crisis.
PM&R specialists also specialize in:
- Early identification: Detecting subtle clinical changes before they escalate
- Anticipating complications: Curbing functional decline, unmanaged pain or mobility deficits
- Proactive oversight: Serving as the first line of defense against avoidable hospital transfers
Serving as Functional and Rehabilitation Consultants
Physiatrists in SNFs do not replace the primary medical team. Instead, they serve as consulting specialists with a targeted focus on:
- Optimizing mobility.
- Managing pain and spasticity.
- Addressing rehabilitation-related risks.
Their expertise equips them to bridge the gap between therapy and medical care — advising primary providers and therapy teams. By ensuring that care plans address both medical complexity and therapeutic progression, physiatrists help close the loop on risks that might otherwise lead to readmission.
Strengthening Teamwide Coordination
Effective readmission prevention requires seamless communication and shared care planning between physiatrists, primary providers, nursing and therapy staff. Their focus on interdisciplinary collaboration helps to promote:
- Timely reporting of clinical findings.
- Collaborative goal-setting.
- Clear delineation of roles and responsibilities.
When communication flows and roles are clearly defined, SNFs can intervene sooner, personalize rehab and dramatically reduce unnecessary hospital transfers.
Clinically Predictable Cases and How to Reduce Hospital Admissions
Most hospital readmissions don’t arrive without warning. They evolve from recognizable patterns of physical decline, unaddressed symptoms or worsening chronic illness.
A physiatry-led approach leverages their specialized expertise to identify these signals early and implement targeted, evidence-based interventions. With structured protocols and close interdisciplinary coordination, physiatrists help SNFs prevent complications before they trigger another trip to the hospital.
Functional Decline and Mobility-Related Issues
Loss of mobility is one of the most common predictors of avoidable hospital transfers in SNFs. When residents experience new difficulty walking, exhibit reduced participation in therapy or are at an increased risk of falls, a domino effect of deconditioning, injury and rehospitalization can quickly follow.
Physiatrists address these risks proactively by setting individualized mobility goals, leading interdisciplinary rounds and closely coordinating therapy interventions. Their ability to identify early warning signs and adjust the care plan in real time keeps residents moving, helping avoid the common pitfalls that too often lead to a hospital return.
Pain, Spasticity and Poor Symptom Control
Uncontrolled pain and spasticity do more than impact comfort — these symptoms can spark acute episodes requiring outside intervention. A physiatrist’s focused approach to early symptom management optimizes pain control and helps care teams fine-tune medication plans.
Chronic Disease Exacerbations
Chronic conditions such as congestive heart failure, COPD and complex neurological diseases frequently drive readmissions when subtle functional changes are overlooked in their early stages. Rather than waiting for abnormal vital signs or overt medical emergencies, physiatrists emphasize functional surveillance that often precedes acute decline, by monitoring:
- Endurance.
- Activity tolerance.
- Subtle mobility shifts.
Integrating these insights into the care plan allows the physiatry-led team to intervene earlier, adjusting therapies, medications and activity levels to keep residents stable and dramatically reduce the risk of return to hospital.
5 Evidence-Based Readmission Prevention Strategies for SNFs
Reducing hospital readmissions is not about chasing emergencies. Your team must have standardized, sustainable processes that anticipate risk, supported by physician leadership and staff engagement. Sustainable improvement is possible through the use of these structured protocols that make readmission prevention a repeatable, teamwide effort — rather than a series of isolated interventions.
1. Align the Team Through Education
A highly trained and empowered team is the backbone of any effective readmission reduction effort. Ongoing education ensures that every staff member, from nursing to therapy, can recognize early warning signs of declining health and understand next steps.
2. Conduct Early Risk Stratification
Early structured assessments that establish a clear functional baseline and detect pain or mobility risks combine insights from therapy, nursing and consulting physicians. This approach allows your team to flag high-risk residents before a crisis and tailor their care plans from the outset.
3. Maintain Vigilance With Ongoing Monitoring and Reassessment
Prevention is a continuous process, not a one-time event. Empower staff to monitor resident trends — not just acute changes. Subtle shifts in mobility, pain levels or function may allow for proactive intervention, stabilizing residents before concerns escalate to the point of hospital transfer.
4. Continue With Interdisciplinary Care Planning
Effective readmission prevention happens when everyone is on the same page. Hold regular interdisciplinary meetings, keep shared documentation up to date and establish unified escalation pathways for emerging concerns. Physician input, particularly from specialists like physiatrists, serves as a stabilizing force, ensuring that care plans address all dimensions of the resident’s needs.
5. Build Sustainability Through Protocols
Foster a culture where every team member knows when and how to escalate concerns, with physicians positioned as expert supports rather than substitutes for nursing judgment.
Partner With Medrina for Proven Readmission Reduction Strategies
Ready to reduce readmissions, improve care coordination and deliver true value-based outcomes in your skilled nursing facility? Medrina’s consulting physiatrists work seamlessly with your care team to provide expert functional assessments and proactive rehabilitation planning. Our approach keeps residents safer, supports staff and positions your SNF as a leader in high-quality post-acute care.
Contact us today to learn how our physiatry-led consulting model can help your facility achieve fewer rehospitalizations and better outcomes.
Chief Clinical Officer
Dr. Cowling is Board Certified in Physical Medicine and Rehabilitation, with a specialized focus on Subacute Rehab, Orthotics and Prosthetics, and the non-surgical management of Musculoskeletal Injuries. He graduated from Michigan State University College of Osteopathic Medicine and completed his residency and specialty training in PM&R at the University of Wisconsin.
Dr. Cowling has a deep passion for teaching and advancing the field of Physiatry in post-acute care. As Chief Clinical Officer at Medrina, he works to spearhead the advancement of physician protocols, education, and communication within the clinical team.
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