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Winning the Readmission Challenge

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When hospitals look at post-acute senior care communities (skilled nursing & assisted living) their criteria are very simple:

  • You can send them patients (first time admits) or you can’t.
  • You can help them reduce readmissions or you can’t.
  • Their patients like your community or they don’t.
  • Your care model is consistent with the hospitals or it’s not.

If you can help in these areas you will be viewed as a strategic asset. If you can’t or won’t, you become an irrelevant entity.

How To Win

There are two departments in every senior community that can make a substantive difference in reducing readmissions.  The nursing/healthcare component is the obvious. Dining services is less obvious, but has the ability to make a substantial difference. Trinity Senior Living with 32 senior housing communities in Indiana, Maryland, Michigan and Iowa made a strategic decision to aggressively create a program of care that would address the need for hospitals to reduce admissions.  The dining service component was a critical part of the program because it is well documented that good nutrition and hydration improves resident wellness. Trinity teamed up with Unidine Senior Dining Services to create the ultimate wellness dining experience that looks like this:

  • Meals, snacks and even purees needs to look, smell and taste great..  Without these elements, residents either won’t eat well and what they do eat, will not have the nutritional components needed to promote wellness.
  • Staff are trained to identify risk factors and respond early to changes in status that indicate increased risk.
  • Menus use high quality, fresh and seasonal ingredients that support the program’s nutritional goals. Fresh herbs are used to season the meals and enhance flavor while reducing use of salt and sugar and eliminating the need for preservatives and other artificial additives.
  • The dining service is closely coupled with Trinity Senior Living, therapy services, activity and educational programs to create a comprehensive coordinated program.
  • Hydration stations use clear, easy-to-operate dispensers with water that is infused with a variety of fresh fruits, vegetables or herbs. The flavors change daily to increase awareness and interest.
  • The resident-centered program is privately branded as Trinity's “Sanctuary” brand to ensure a consistent, recognizable and trusted presence across the system


How effect a program like this is, consists of answering two questions:

1.  Is resident health improving and are hospital readmissions dropping?

 2. How much does it cost?


Trinity is seeing significant measurable positive outcomes in areas that include:  congestive heart failure, diabetes, hypertension, acute and chronic kidney disease, dyslipidemias, dehydration and un-prescribed weight loss with an end result of reducing readmissions.


It turns out that doing it the new old fashioned way (the real old fashioned way was all fresh and local ingredients) with pre-cut, pre-packaged or prepared convenience foods can be more expensive than fresh, natural ingredients. All of this processing comes at a cost that is borne by the senior community while the residents pay in the form of lower quality and diminished nutritional value. Trinity and Unidine have managed to improve quality and clinical outcomes while controlling – and in some areas dramatically reducing – the cost of the program. You can download the complete case study:  Integration of Dining & Nutrition for Coordination of Care and Reduction of in Readmission Rates.  

By following the link you can also access an on demand webinar where the authors of the case study discuss their results. Steve Moran


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