It’s a scenario with which long-term care physicians are quite familiar: Mrs. A is discharged from the hospital to a skilled nursing facility on a Friday night. On Saturday, she develops a deep cough and fever and ends up back in the hospital. Such a readmission could have been prevented, and now that Medicare’s readmission penalties have kicked in, more hospitalists are investigating systems and models to help them improve their rates of readmissions from nursing homes. Under the Affordable Care Act, Medicare began on Oct. 1 to penalize hospitals – up to 1% of their overall Medicare payments – with excess readmissions for pneumonia, heart failure, and myocardial infarction. The penalty for this fiscal year (Oct. 1, 2012–Sept. 30, 2013) is based on hospital performance between July 2008 and June 2011 and will be adjusted per hospital based on patient demographics, comorbidities, and frailty. Hospitalists are looking to skilled nursing facilities for help. Readmissions such as Mrs. A’s could be prevented if physicians had a stronger presence at the skilled nursing facility (SNF) level, according to Dr. Darius K. Joshi of the University of Michigan, Ann Arbor. At the University of Michigan Health System, a small team of geriatricians and nurse practitioners, led by Dr. Joshi, has been assigned to staff local SNFs 7 days a week. The goals are both to discharge patients from the hospital to SNFs sooner and to keep them from being readmitted. The subacute care program reduced the average hospital length of stay before transfer to a SNF from 10.6 days to 8 days between 2006 and 2011. The hospital’s 15-day readmission rates dropped from 20% to 17% over the same period ( JAMDA 2012;13:564-7). “Being at the bedside, seeing these patients, knowing their history, having good laboratory tests available, avoids sending many of these patients back to the hospital,” said Dr. Joshi, a member of the geriatric medicine division at the University of Michigan, where he runs the subacute-care program. Doctors and nurse practitioners practicing in the University of Michigan Health System’s SNFs also have access to the health system’s electronic health record (EHR) system. This allows physicians at an SNF to understand the patient’s hospital care, and it transfers data on care provided at the SNF back to the hospital. But even with this effort, the system will face a 0.64% cut under the Hospital Readmissions Reduction Program in FY 2013. “[Readmissions are] a very, very resistant problem with our patients,” Dr. Joshi explained. Many times, families may insist that their loved ones go to the emergency department when their conditions worsen. In the case of falls, there is little alternative to returning to the hospital because most SNFs don’t have appropriate imaging equipment. “There are limitations in what we can do, but if there’s any chance of cutting down readmissions, it needs to be with bedside presence,” Dr. Joshi said.