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Four Practical Steps to Reduce Hospitalizations in AL in 2024

By 2025, Centers for Medicare and Medicaid Services (CMS) wants to transition 50% of commercial and Medicaid contracts to a value-based model. By 2030, CMS wants 100% of Medicare and a majority of Medicaid recipients to be enrolled in VBC.1 That’s just over six years away, and comes the year after another significant milestone that is reshaping senior care: by 2029, every Baby Boomer will be at least 65 years old.

VBC models prioritize quality of care over quantity and focus on health outcomes. Take hospitalizations, for instance. An AL resident’s risk of hospitalization ranges from 25% to 61%.2,3 Residents also experience twice as many hospitalizations and deaths as their independent living counterparts during the first year of stay, and nearly 39% of those discharged from the hospital are readmitted within 90 days3.

This is not only costly and highly traumatic for residents, but expensive for operators who risk the expense of caring for high-acuity residents, staff overtime and/or turnover, and increased move-outs. Hospitalizations are also costly to taxpayers, costing approximately $25 billion in annual U.S. health care spending4.

Under VBC models, AL communities have multiple incentives to reduce hospitalization rates. Here, then, is a look at four practical steps that AL operators can take to reduce hospitalizations in 2024.

  1. Take a fresh perspective

Encouraging AL leaders, staff, residents and families to embrace a perspective on health care that’s focused on prevention is a great first step to reducing hospitalizations. Yet to truly move the needle on hospitalization rates in the coming year, these stakeholders must be aligned and develop a collaborative path forward.

Community staff at all levels should feel they’re part of the solution and be encouraged to share ideas and insights into essential questions such as:

  • What is the most common reason for hospitalizations among our residents?
  • What is our biggest obstacle in reducing hospitalizations?
  • What resources are needed to overcome this obstacle?

Standardized early warning tools like INTERACT® (Interventions to Reduce Acute Care Transfers) Stop and Watch can help promote a culture of health care prevention. They’re designed to detect early changes in a resident’s health status, prompting staff to intervene before the condition worsens.

“Empowering and educating everyone from laundry to maintenance with tools like Stop and Watch, while ensuring everyone’s buy-in and recognizing each as an integral part of the care team, is essential,” says Peggy McGhee, Vice President of Clinical Services with Willow Health Care, Inc. “Engaging families and teaching them to use these tools is also crucial because they know their loved ones best. Moreover, engaging practitioners to be attentive and receptive to subtle changes in residents is vital, as proactive care always yields better outcomes. It’s imperative to encourage residents to communicate about their well-being, as they know their bodies the best.”

To ensure long-term success, AL communities need to foster a “see something, say something” environment. Culture changes in any company typically involves the need for training and education and on-going support. AL communities are no different.

With proper training, every AL stakeholder can recognize and proactively respond to subtle changes in resident health, including new coughs, loss of appetite, agitation, restlessness and fatigue. They’d also be empowered to flag concerns. Leadership, when given these health updates, would take the information seriously and know what information to share with the resident, family, and the resident’s physician.

  1. Recognize the importance of vaccinations and medication regimen optimization

Low vaccination rates within AL communities, polypharmacy and potentially inappropriate medications have all been linked to increased all-cause hospitalizations. For older adults, flu vaccines can reduce flu-associated hospitalizations by about 40%5. This is a significant reduction that residents and families would want to know. Other recommended immunizations include pneumococcal, COVID-19 and shingles vaccines.

With falls a leading cause of preventable hospitalizations in older adults, addressing modifiable risks like polypharmacy and falls-related medications are critical. Effective fall prevention strategies include discontinuing unnecessary or inappropriate medications and interventions targeting specific medication classes, such as antipsychotics and anti-anxiety medications.

Monitoring the risk of high-risk medications can also reduce hospitalizations, whether a blood thinner like warfarin or anti-diabetic agents including sulfonylureas and insulin.

  1. Focus on transitions in care

Transition from one care environment to another is an especially vulnerable time for older adults. That’s because many health care providers are working to help the resident get better but aren’t necessarily communicating with each other (i.e., fragmentation). That’s why seamless care transitions into AL from home, skilled nursing or acute care play an important role in averting hospitalizations.

”Effective care transitions should include a thorough medication reconciliation and ensuring follow-up appointments with physicians and specialists are kept,” McGhee says. Known as a “Med Rec,” which research shows can significantly reduce hospitalizations and readmissions, this process involves comparing a resident’s medication lists from various sources to establish the correct regimen.

  1. Leverage strategic partnerships to expand your community’s clinical acumen

Due to staffing differences in AL compared to skilled nursing facilities, one key AL strategy for reducing hospitalizations is to proactively cultivate strategic partnerships, aligning with partners who understand and share their goals, including physicians groups, therapy providers and long-term care (LTC) pharmacies. These alliances serve to deepen the clinical bench, reduce fragmentation and further enhance resident well-being.

“Because medications can be high drivers of hospitalizations, it’s especially important that the AL community relies upon the expertise and guidance from their LTC pharmacy partner,” says Lisa Lassiter, RPh, Director of Clinical Services for Guardian Pharmacy of South Georgia. For instance, as key members of each resident’s health care team, LTC pharmacy staff can:

  • Proactively review medication regimens to identify high-risk drug combinations, doses that are too high or too low for residents, and drugs a resident should be on
  • Reconcile medication lists from various sources to determine the correct drug regimen for the resident
  • Promote medication adherence, which is a proven strategy to avert hospitalizations, through use of compliance packaging and aligning drug regimens with insurance formularies to reduce costs for residents
  • Be a resource for AL staff, residents, families and physicians to answer drug-related questions and provide no-nonsense vaccination information
  • Provide on-site education for AL care teams on hot-topics such as high-risk medication use and fall prevention

“Pharmacists suspect medications first with any change in resident condition,” Lassiter says. When employed by the AL as part of the onsite multi-disciplinary team, a consultant pharmacist can help monitor residents at risk for hospitalizations and make recommendations to optimize medication regimens. “If the AL will engage a pharmacist, they can perform falls evaluations, a holistic review of their medication regimen, explore reasons for medication non-adherence and reduce the incidence of polypharmacy.”

Because pharmacists understand the important role vaccines play in reducing hospitalizations, Lassiter adds, “LTC pharmacies can help increase vaccination rates in AL by facilitating onsite vaccine clinics, advocating for vaccine uptake and educating residents, families and staff about the benefits of vaccinations.”

In the end, following these four steps is better for everyone. A new approach means residents live in their communities longer with better quality of life. The community’s operational and financial performance can improve, leading to high staff and leadership satisfaction.

This article is sponsored by Guardian Pharmacy Services. To learn more about the benefits of a Guardian Pharmacy partnership for senior living operators, visit

  2. Bartley MM, Quigg SM, Chandra A, Takahashi PY. Health Outcomes From Assisted Living Facilities: A Cohort Study of a Primary Care Practice. J Am Med Dir Assoc. 2018 Mar;19(3):B26. doi: 10.1016/j. jamda.2017.12.079. Epub 2018 Feb 21. PMID: 32774179; PMCID: PMC7410296.
  3. Caffrey C, Harris-Kojetin L, Rome V, Schwartz L. Relationships Between Residential Care Community Characteristics and Overnight Hospital Stays and Readmissions: Results From the National Study of Long-Term Care Providers. Seniors Hous Care J. 2018 Nov;26(1):38-49. PMID: 31105807; PMCID: PMC6520986.
  4. Nyweide DJ, Anthony DL, Bynum JPW, et al. Continuity of Care and the Risk of Preventable Hospitalization in Older Adults. JAMA Intern Med. 2013;173(20):1879–1885. doi:10.1001/ jamainternmed.2013.10059.
  5. Centers for Disease Control and Prevention. (2023, February 8). Vaccine effectiveness: How well do flu vaccines work?. Centers for Disease Control and Prevention. vaccineeffect.htm.

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