Hospital readmissions remain one of the most persistent challenges for long-term post-acute care (LTPAC) facilities. National data shows that roughly 13% to 14% of all hospitalized patients are readmitted within 30 days (Burke et al., 2022). But the rate among nursing home residents can climb significantly to 20% to 25% (Kristensen et al., 2025), underscoring the vulnerability of this population. In addition to financial penalties, each avoidable return to the hospital disrupts the continuity of care, undermines resident and family trust, and adds stress to staff already stretched thin.
Clearly, no single discipline can prevent readmissions alone. Success requires a leadership-driven interdisciplinary approach that combines clinical vigilance with seamless communication and family engagement. At the center of this effort, the director of nursing services (DNS) can serve as a unifying force to transform fragmented practices into coordinated systems of care. This article explores how to harness the power of interdisciplinary collaboration, data-driven insights, and family engagement to turn the tide on avoidable readmissions.
Understanding the Drivers of Readmissions
Readmissions are rarely the result of a single failure. Instead, they often stem from a series of preventable issues: medication errors, unmanaged chronic conditions, infections, gaps in care transitions, falls or accidental injuries, or delayed recognition of a decline. Each of these risks are magnified in the LTPAC environment, where residents are frail, medically complex, and highly dependent on skilled oversight.
A DNS who can see beyond the numbers by identifying the human and organizational costs of rehospitalization sets the tone for the entire team. When leaders frame readmission prevention as a matter of resident dignity, safety, and staff morale, the interdisciplinary team (IDT) is more likely to engage wholeheartedly in the process of change.
Bridging the Gap: Transitional Care That Works
The transition from hospital to facility is one of the most fragile points in a resident’s journey. Evidence shows that structured transitional care programs can significantly lower readmission rates when led by nursing teams trained in discharge coordination (Fønss Rasmussen et al., 2021). Effective transitions focus on these strategies:
- Individualized care plans
- Early post discharge follow-ups
- Resident and family education
Nurse transition coaches or care coordinators can serve as the linchpin of these efforts, proactively identifying red flags and ensuring care gaps are closed within the first 30 days. Pairing these actions with practical education strategies, such as the teach-back method and culturally appropriate communication in the preferred language, empowers families to become partners in the process rather than bystanders.
The Medication Minefield
Medication-related errors remain one of the top causes of preventable hospital returns. Adverse drug reactions, drug interactions, and polypharmacy often go undetected until a resident becomes unstable. These problems are frequently tied to gaps in medication reconciliation during transitions of care, miscommunication or under-communication between providers, or missed doses due to resident non-adherence or staff workflow challenges. Just as concerning is that residents are not always monitored adequately for early signs of side effects or toxicity that can escalate into the need for a hospital transfer.
Although these challenges are daunting, they also present an opportunity for improvement. By reinforcing the medication review processes, sustaining comprehensive reconciliation, and training staff to recognize early warning signs, avoidable hospital readmissions can be substantially reduced. Studies show that effective medication reconciliation can lower hospital returns by up to 30% (Zemaitis et al., 2016).
Collaboration among nurses, pharmacists, and prescribers is essential to create this safety net for vulnerable residents. Together, the care team can take these steps:
- Review and reconcile prescriptions
- Eliminate duplications or contraindications
- Ensure residents and families understand new medication regimens
In addition, nurses must be taught that if they have a question or even forget what the provider instructed, they must reach out for clarification. This simple but essential practice strengthens provider trust, prevents errors from compounding, and helps safeguard residents from avoidable harm.
When done consistently, these practices not only prevent rehospitalizations but also build resident and family trust in the facility’s ability to provide safe, attentive, and accurate care.
People and Processes: Staffing, Data, and Teamwork
Readmission prevention does not happen in silos; it requires both well-trained professionals and effective processes. Higher nurse-to resident ratios, coupled with targeted training in topics such as sepsis recognition, wound care, fall prevention, and chronic disease management, give frontline staff the tools they need to act early.
In addition, predictive analytics and data dashboards offer a layer of insight to care planning. Facilities that integrate hospital electronic health record data, track vital sign trends, and flag high-risk residents can intervene before a transfer to the hospital becomes the only option. Regular interdisciplinary rounds and care conferences then knit these insights into shared action, ensuring no discipline is left working in isolation.
Evidence-based communication and assessment tools, such as the INTERACT Stop and Watch Early Warning Tool and Situation, Background, Assessment, and Recommendation (SBAR), are crucial. These structured approaches empower staff to identify subtle changes in a resident’s condition, escalate concerns clearly and appropriately, and communicate effectively with providers. Consistent use of such tools not only improves clinical accuracy but also strengthens physician/provider confidence in staff assessments. When physicians trust the frontline team, they are less likely to send residents out unnecessarily, trusting in the care received in the facility and thus avoiding disruptive hospital transfers.
Leading the Charge: DNS as the Catalyst for Change
Although every discipline plays a role, the DNS provides the glue. Successful leaders embed evidence-based practices into workflows, align staff competencies with measurable outcomes, and foster a culture where accountability is the norm rather than the exception.
Leadership rounds, near-miss reviews, and performance dashboards all reinforce progress, but culture change sustains it. To support this, leaders can leverage structured resources such as AAPACN’s “Action Plan: Hospital Readmissions” tool to guide the team step by step through identifying trends, setting measurable goals, assigning responsibilities, and tracking results. By turning data into a clear roadmap for improvement, the tool ensures that interventions do not stall at mere discussion but instead move forward into sustainable action.
When leaders model consistency, mentor staff, and create psychological safety for reporting concerns, they build a workforce confident in its ability to keep residents stable and out of the hospital.
From Avoidable Returns to Sustained Outcomes
Preventing hospital readmissions is far more than a regulatory requirement. It is a commitment to preserving residents’ quality of life, empowering families, and strengthening the entire care team. When the IDT unites around transitional care, medication safety, predictive data, and structured improvement strategies, the DNS can create a culture where safe, competent, and consistent care is the norm. In such an environment, unnecessary hospitalizations become the rare exception rather than the rule.
The true reward extends beyond improved metrics. It is the assurance that every resident experiences care that is not only sound, but also coordinated, compassionate, and deeply respectful of their dignity.
References
Burke, R. E., Xu, Y., & Rose, L. (2022). Skilled nursing facility performance and readmission rates under value-based purchasing. JAMA Network Open, 5(2). https://doi.org/10.1001/jamanetworkopen.2022.0721
Fønss Rasmussen, L., Grode, L. B., Lange, J., Barat, I., & Gregersen, M. (2021). Impact of transitional care interventions on hospital readmissions in older medical patients: A systematic review. BMJ Open, 11(1). https://doi.org/10.1136/bmjopen-2020-040057
Zemaitis, C. T., Morris, G., Cabie, M., Abdelghany, O., & Lee, L. (2016). Reducing readmission at an academic medical center: Results of a pharmacy-facilitated discharge counseling and medication reconciliation program. Hospital Pharmacy, 51(6), 468–473. https://doi.org/10.1310/hpj5106-468
This AAPACN resource is copyright protected. AAPACN individual members may download or print one copy for use within their facility only. AAPACN facility organizational members have unlimited use only within facilities included in their organizational membership. Violation of AAPACN copyright may result in membership termination and loss of all AAPACN certification credentials. Learn more.