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Telehealth is increasingly becoming an integral part of post-acute care in various settings such as skilled nursing facilities, inpatient rehabilitation facilities, long-term acute care hospitals, and in the home health and hospice care settings. As healthcare moves more towards value-based models that focus on quality outcomes and keeping patients healthy at home whenever possible, telehealth provides opportunities to enhance care coordination, improve access to specialty providers, and reduce readmissions from post-acute care settings back to hospitals. Some of the key ways telehealth is being used in post-acute care include:

Remote Patient Monitoring: Many post-acute care patients, especially those with chronic conditions, can benefit from ongoing remote monitoring of vital signs and symptoms at home. Conditions like congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes and wound care are well-suited for remote monitoring. Devices can track things like blood pressure, heart rate, oxygen saturation, weight, and glucose levels and transmit the data via Bluetooth or Wi-Fi to the patient’s clinicians for review. This allows earlier detection of potential issues before they worsen and require a readmission. It also empowers patients to better self-manage their conditions at home with oversight from their care team.

Video Conferencing Visits: Secure video conferencing provides a way for clinicians to remotely “visit” with their post-acute patients to assess their conditions, answer questions and ensure treatment plans are on track for recovery and health maintenance. This is useful for providers to conduct virtual follow-up visits for things like wound care, medication management and therapy progress without requiring an in-person trip back to the facility or specialists’ offices. Therapy telehealth visits allow physical, occupational and speech therapists to remotely guide patients through exercises and provide training.

Specialty Consultations: Accessing specialty provider expertise can sometimes be challenging for post-acute facilities located in rural areas. Telehealth enables on-demand access to cardiologists, dermatologists, neurologists and others to evaluate patients as needed. Specialists can remotely examine patients, diagnose issues, adjust treatment plans and recommend additional testing or interventions to the bedside clinicians. This reduces transfers to hospitals or delays in advanced care. Tele-stroke programs similarly allow rapid neurology evaluations for acute stroke patients in remote facilities.

Discharge Planning & Care Transitions: Care coordinators use video visits to remotely prepare patients and families for discharge to lower levels of care or home. This could involve medication teaching, home safety evaluations, therapy scheduling and answering questions. Post-discharge remote follow ups via telehealth then allow earlier identification of any difficulties and opportunities for intervention to prevent readmissions. Virtual hospital rounding programs also utilize telehealth to better coordinate care as patients transition between acute and post-acute levels of care.

Staff Support & Education: Telehealth provides opportunities for off-site specialists, supervisors and educators to remotely support staff in post-acute facilities. Examples include consultations on complex patients, supervision and feedback on therapy techniques or wound care practices, teaching sessions on new policies/procedures and virtual observation of patient interactions to ensure quality and regulatory compliance. This enhances skills and knowledge while reducing travel time away from patient care duties.

Facility Usage Examples: Some real world examples of telehealth integration in post-acute care include:

A 200-bed skilled nursing facility in New York developed a comprehensive remote patient monitoring program utilizing Bluetooth-enabled devices. It reduced 30-day readmissions by 23% and led to earlier interventions for potential issues.

An inpatient rehabilitation hospital in Texas conducted over 7,500 video therapy and specialty telehealth visits in 2020, allowing continued treatment during the pandemic’s visiting restrictions while avoiding unnecessary transfers.

A home health agency partnered with a major hospital system to launch virtual hospital-at-home programs using remote patient monitoring. Initial data showed readmissions were 57% lower than similar in-patients.

A long-term acute care hospital collaborated with neurologists at a large medical center to run a tele-stroke program. Over 90% of patients received a same-day remote neurology evaluation and management plan compared to average 2 day wait previously.

As policymakers and payers increasingly recognize telehealth’s benefits, its role in post-acute care coordination and disease management will likely expand further in the coming years. Outcomes data thus far indicates telehealth technology can reduce costs while maintaining or improving quality of care and patient/family satisfaction during recovery and transition periods. With clinicians facing workforce shortages as well, telehealth ensures geography is not a barrier to accessing specialists and continued recovery support.


Post-fall huddles and reviews are standard care practices implemented by many healthcare organizations to systematically evaluate fall events among patients. The goal of these processes is to identify factors that may have contributed to a fall, mitigate future risks, and prevent repeat falls. After a patient experiences a fall, a multidisciplinary team typically conducts a prompt huddle at the bedside while details are still fresh. They then conduct a more formal review within 1-2 days to analyze findings in depth.

At my facility, we have worked hard over the past year to strengthen our focus on falls prevention as rates had been slowly creeping up. As part of our quality improvement efforts, we began mandating post-fall huddles immediately after any fall and follow-up reviews within 24 hours led by our falls committee. This allowed us to gather a wealth of insightful findings that are helping us better understand falls risks and implement targeted safety interventions.

Some of the most frequently identified contributors to falls uncovered through our huddle and review processes included: a lack of call light usage by patients, gaps in communication of fall risks on shift change handoffs, noncompliance with fall prevention interventions like alarm activation and hip protectors, missed rounds by nursing staff, and an insufficient number of staff to provide needed assistance in a timely manner. Environmental factors like uneven flooring, lack of secure handrails, and poor lighting were also flagged in certain areas as physical plant issues meriting examination.

We also found that patients presenting with certain medical conditions or recently prescribed new medications appear to be at heightened risk and warrant especially close monitoring. Conditions like delirium, confusion, new weakness, and gait instability emerged as common themes among those who sustained injurious falls. New medications that may cause dizziness, drowsiness, or impair balance seemed to interact as risk multipliers as well. Comorbidities like arthritis, impaired vision, and history of prior falls further compounded these risks.

Through analyzing fall circumstances in detail, some falls could likely have been prevented with more astute screening of intrinsic and extrinsic risk factors during admission assessments. Our reviews highlighted opportunities to bolster comprehensive geriatric assessments and apply standardized screening tools to systematically identify individuals’ personal fall histories, mobility limitations, cognitivefunction, vision deficits, and medication regimens that signal increased concern. We also found variable compliance with recommended fall prevention orders across units depending on available staffing resources and competing priorities.

Reviewing nursing documentation provided insights into human factors as well. Some falls occurred when proper assistance was not provided during high-risk activities like toileting/transfers due to staff distractions or simultaneous demands on multiple patients. Communication gaps were also implicated – like when day and night shift nurses failed to exchange all key details about fall risks during handoffs. This points to the need for more reliable standardized communication practices and enhanced teamwork/situational awareness training.

Our falls committee also probed contributing organizational factors. Workload issues, staffing shortages, and high patient volumes contributed to limited time for education, individualized care planning, and consistent implementation of nonpharmacologic fall prevention strategies. Adhering to recommended staffing ratios and skill mixes surfaced as an ongoing challenge. Equipment issues also became evident, such as nonfunctional call lights or beds/chairs lacking appropriate safety features.

This comprehensive evaluation of circumstantial, clinical, human, and system factors through huddles and reviews has generated an invaluable roadmap. We are now better positioned to implement highly targeted multi-pronged interventions shown to make the biggest impact. Actions underway include bolstering admission assessment consistency, improving communication practices, redesigning high-risk spaces, strengthening individualized care planning, enhancing staff education/competencies, and advocatingfor necessary staffing and equipment resources. With continued diligence, I’m hopeful our revised approach will yield safer patient outcomes and lower preventable fall rates over time. The insights gained through post-fall assessment refinement have certainly equipped us to move the needle on this important quality and safety issue.


Ensuring patients have access to necessary post-discharge services is critical for facilitating recovery and preventing readmissions. There are several strategies healthcare providers can utilize.

First, providers must conduct comprehensive discharge planning which assesses what services each patient will need after leaving the hospital such as medication management, wound care, physical therapy, skilled nursing, home health, etc. This planning should ideally begin on admission so there is sufficient time to coordinate everything. During the planning process, providers need to screen for any social determinants of health risks like food/housing insecurity which if unaddressed could negatively impact outcomes.

Second, providers need to verify that patients being discharged have all the necessary medical equipment, supplies, medications they require as well as instructions for how to use everything and who to contact with any questions or issues that arise. This often involves working with durable medical equipment companies, pharmacies, and home health agencies to ensure everything is in place and operational by the time patients leave.

Third, providers need to conduct patient education prior to discharge regarding their diagnosis, treatment plan, warning signs that should prompt contacting a provider, and how to self-manage their condition at home. This education often involves multimodal teaching methods like verbal and written instructions plus return demonstrations to evaluate comprehension. It is also important for education to involve family members or caregivers who will be assisting patients.

Fourth, providers need to make timely post-discharge follow up appointments with primary care providers or specialists, as appropriate, before patients leave the hospital. This involves direct scheduling of appointments which may require addressing any transportation barriers. Following up within 7-10 days of discharge has been shown to reduce readmissions. Additional interventions like transitional care clinics or in-home visits can help bridge the time until a follow up appointment occurs.

Fifth, providers need to leverage technology and community resources to support patients post-discharge. This includes ensuring patients enroll in remote monitoring programs if applicable for their condition and prescribed treatments which allow providers to keep tabs on vital signs and progress from a distance. It also means ensuring patients are aware of and connected to any applicable community-based support programs for things like Meals on Wheels, food banks, transportation assistance, adult day care, homemaking help, support groups, etc.

Sixth, providers need robust discharge communication with outpatient providers including primary care physicians and specialists. This involves sending timely and comprehensive discharge summaries that detail the hospitalization, procedures, treatments, changes to medications or treatments, follow up needs, and open clinical questions. Strong bidirectional communication helps outpatient providers take over care seamlessly and addresses any gaps preemptively.

Seventh, healthcare systems and institutions need to closely track metrics like 30-day readmission rates, ED visit rates, and patient/family experience surveys specifically focused on transitions of care in order to identify gaps, continually refine processes, and ensure accessibility of post-discharge services according to community need. This may require facilities partnering with community organizations, expanding existing programs, or piloting new initiatives based on data trends.

By implementing comprehensive discharge planning that begins early, verifying patients have necessary medical equipment and instructions, conducting proper patient/caregiver education, making timely follow up appointments, leveraging technology and community resources, sending robust communication to outpatient providers, and closely tracking post-acute outcomes – healthcare providers can significantly improve patients’ access to vital post-discharge services needed for recovery and meeting their goals of care. Coordinated, patient-centered planning from admit to well after discharge is key.