Preventing Rehospitalization

Sherry Johnson
February 19, 2019
As [a new] plan is implemented and staff knowledge and skills increase, the resident care outcomes will also improve. Decreasing readmission to the hospital is attainable as long as the team works together!

The Director of Nursing (DON), in the Skilled Nursing Facility, sets the expectations of care through their leadership, communication, and the systems implement.  Ensuring that there is a sufficient number of staff competent to care for the residents is the key to delivering quality care and reducing the likelihood of hospital readmission.  Let’s look at some ways this is done.

Competency Management

Competency, as defined by the American Nursing Association, is “an expected level of nursing performance that integrates knowledge, skills, abilities, and judgment” (Nursing: Scope and Standards of Practice, 2015).  Standardized tools are used to assess competency of the nursing staff.  The Nursing Professional Development practitioner (NPD) “analyzes issues, trends, and supporting data to determine the needs of individuals, organizations, and communities in relation to health care” (Harper & Maloney, 2016).  Specific hospital readmission rates, common trends for residents who are discharged and return, and any other adverse care outcomes are some of the data points the NPD will analyze.

The Centers for Medicare & Medicaid Services (CMS) recently released a new toolkit, the Nursing Home Staff Competency Assessment (Nursing Home Staff Competency Assessment, 2018).  This toolkit describes four purposes of a competency assessment including

  • Identifying individual strengths
  • Detecting both individual and the nursing team’s learning needs
  • Boosting professional development, and
  • Increasing job satisfaction

Behavioral, technical, and resident-based sections are included in the toolkit assessment and it provides a great opportunity for personal responsibility and professional development for the staff and nursing leadership alike.  Nine to eleven competencies are included in each section (see Table 1 below) for the Certified Nursing Assistant and Certified Medication Technician assessment.

Table 1.  Competency Categories for CNA/CMT Positions
Each of the three sections of the assessment will assist the DON and NPD in identifying learning needs of the staff.

Behavioral Competencies

  1. Advocacy
  2. Communications
  3. Conflict Resolution
  4. Education & Training
  5. Ethics
  6. Leadership
  7. Problem-Solving
  8. Professionalism
  9. Teamwork & Collaboration
  10. Time Management & Adaptability

Technical Competencies

  1. Activities of Daily Living (ADLs)
  2. Admission, Transfer, and Discharge
  3. Detecting Resident Change in Condition
  4. Documentation
  5. Infection Control and Prevention
  6. Medication Administration (CMT only)
  7. Pain Management
  8. Person-Centered Care
  9. Quality Assurance Performance Improvement (QAPI)

Resident-Based Competencies

  1. Chronic Obstructive Pulmonary Disease (COPD)
  2. Congestive Heart Failure (CHF)
  3. Dementia/Cognitive Impairment
  4. Diabetes Mellitus
  5. Impaired Mobility
  6. Mental Health
  7. Pneumonia
  8. Pressure Ulcers/Injuries
  9. Resident Falls
  10. Urinary Incontinence (UI)
  11. Urinary Tract Infection (UTI)

(Nursing Home Staff Competency Assessment, 2018).

Team Approach

Creating a positive learning and practice environment involves everyone.  Once the learning needs of the staff are identified, the NPD works with the nursing leadership team to implement an education plan that will close these practice gaps.  As the plan is implemented and staff knowledge and skills increase, the resident care outcomes will also improve.  Decreasing readmission to the hospital is attainable as the team works together!


Harper, M. G., & Maloney, P. (2016). Nursing Professional Development: Scope & Standards of Practice, 3rd Edition. Chicago: Association for Nursing Professional Development.

Nursing Home Staff Competency Assessment. (2018, November). Retrieved from

Nursing: Scope and Standards of Practice. (2015). Silver Springs, MD: American Nurses Association.

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