How to improve readmission rates with MDS nurses

Watershed Health announces SNFConnect to streamline patient transitions for skilled nursing facilities & home health agencies to meet the new CMS requirements Lack of transparency and shared information between SNFs, home health agencies, and acute-care providers puts patients at risk and drives up costs. We are closing these gaps with SNFConnect, which unlocks critical patient information and automates real-time notifications for SNFs around patient events—improving care transitions, reducing readmissions, and supporting compliance with the latest CMS mandates. With SNFConnect, SNFs can: - Easily meet new CMS rules for admission, follow-up, and discharge—no new staffing or EHR changes needed - Cut manual workflows by up to 50% and free up staff to focus on patient care - Receive automated alerts about patient transitions, admissions/discharges, or emergencies - Access actionable analytics to identify high-risk transitions and improve population health management Today’s regulatory changes, including the 2025 CMS mandates, demand better coordination. With 30-day readmissions, approximately 22% of patients admitted to SNFs are readmitted to the hospital within that time frame, and one-fourth to two-thirds are preventable. SNF Connect bridges gaps and empowers every partner in the ecosystem with information that flows seamlessly between care teams. “SNFs are facing critical staffing shortages and financial challenges and are tasked with meeting these new stringent CMS requirements. By offering digitally connected care coordination and information sharing with their acute care partners, SNF Connect helps free up time for staff, deliver better outcomes for patients, make compliance easy, and boost facilities’ bottom line,” said Effie Carlson, CEO of Watershed Health. We would love to meet with you at the Alabama Nursing Home Association Annual Convention and Trade Show September 23-26 at Booth 26!  Reach out to michelle.trimble@watershedhealth.com. Learn more about how SNFConnect transforms care transitions and CMS compliance. https://lnkd.in/gqKA3am4

Making Healthcare Accessible: A Conversation with Dr. Tyres Ford 🏥 What does it mean to truly serve your community? Dr. Tyres Ford, Family Nurse Practitioner, shows us through his work at Greater Baden Medical Services in partnership with Mission of Love. In this 60-second feature, Dr. Ford shares how his team is breaking down barriers to healthcare access in the DMV area—offering everything from preventative screenings and flu testing to EKGs and connections to essential services like dental care and family planning. His message is clear: Prevention over reaction. For too many in our community, healthcare has been out of reach. But with open doors and a commitment to comprehensive care, Dr. Ford and his team are changing that narrative—one patient at a time. "We're here to service the community and we hope to see you soon." 💙 Key Services Highlighted: ✅ Blood pressure & diabetes screenings ✅ Cholesterol testing ✅ Flu, COVID, and strep testing ✅ EKG heart monitoring ✅ Referrals to dental, vision, and family planning services This is what healthcare equity looks like. This is what showing up for your community looks like. #HealthcareAccess #CommunityHealth #MissionOfLove #DMVHealthcare #PreventativeCare #HealthEquity #FamilyMedicine #NursePractitioner #ServingTheCommunity #Greaterbadenhealthcare

Aidoc is proud to announce another significant partnership and successful clinical go-live with OhioHealth! This collaboration includes integration of our Aidoc aiOS™ platform, 20 use cases deployed enterprise-wide, and our Mobile Care Coordination for Acute Stroke workflows in approximately 30 institutions across the OhioHealth system. We're especially proud of our deployment in the Mobile Stroke Treatment Unit, a true testament to our shared mission. Thank you to our partners at OhioHealth and the Aidoc team for making this go-live a success. This collaboration is a step toward delivering faster and more connected care for patients across Ohio. “The Aidoc Team provided a seamless integration for our stroke team and continues to provide outstanding support after implementation.” Michelle Hill, MS, RN, AGCNS-BC, CNRN, SCRN Administrative Nurse Manager, OhioHealth Clinical Enterprise Stroke Network #MobileStrokeUnit #StrokeCare #HealthcareInnovation

Another strong example of AI at scale: Aidoc’s aiOS™ platform, 20 AI use cases, including acute stroke workflows are now live across ~30 OhioHealth institutions, including their Mobile Stroke Treatment Unit 🚑🧠 This is how successful AI platform deployment should look like.

Developed by nurses in the Emergency Department at Great Western Hospitals NHS Foundation Trust, UniWee™ is an innovative device that has been commercialised in collaboration with OMNI-PAC GROUP to provide female patients who are unable to walk with a dignified, pain-free way to urinate whilst sitting or lying down. As part of our support to the team at GWH, Health Innovation West of England commissioned Unity Insights to produce a cost-benefit analysis tool and high-level carbon impact analysis of the UniWee™ in the neck of femur pathway in the average NHS hospital in England. The analysis conducted by Unity Insights demonstrates that over one year, an average NHS hospital in England could deliver an estimated net benefit of £24,817 and a benefit-cost ratio of 19.4 by using the UniWee™ in the neck of femur fracture pathway. This suggests that for every £1 invested, £19.40 of value could be returned. Find out more: https://lnkd.in/epk5pqqv Jennifer Garner Rachel Davis (née Churchman) Cheryl Scott Alex Leach Mairead Murphy Fay Maddock

🏥➡️🏡 From Hospital to Home: The Critical Transition One of the most vulnerable times for patients—especially seniors—is the moment they move from a hospital, rehab center, or skilled facility back to their home. Without the right support, this transition can be overwhelming. Care plans may be misunderstood, medications missed, follow-ups delayed—and too often, this leads to avoidable re-admissions. That’s where Home Care and Personal Assistance Services (PAS) step in. ✅ We help patients safely follow their care plans after discharge ✅ We support them with daily living activities—while protecting their dignity and independence ✅ We give families peace of mind, knowing their loved ones are not alone in this journey ✅ And most importantly, we become partners to hospitals, rehab centers, nursing facilities, and mental health institutes in improving population health Home care is not just about assistance—it’s about building a continuum of care that keeps patients safer, healthier, and at home where they want to be. 🌟 As a physician turned healthcare quality & patient safety leader, and now a home care executive, I’ve seen how this partnership can transform outcomes. Together, we can reduce re-admissions, strengthen trust, and make healthcare truly patient-centered. 👉 To my colleagues in healthcare: Let’s explore how we can collaborate to ensure smoother transitions and healthier communities.

Why hospital EHRs don’t work in care homes Our team has researched many Pflegeheime in Germany and Austria and found that most are stuck with systems built for hospitals. That means: 🔹 Hospitals focus on short stays, diagnostics, and doctor-centered workflows. 🔹 Care homes need daily care notes, long-term resident records, staff handovers, and family communication. Research from PMC (2025) confirms this mismatch: 🔹 Nurses spend more time clicking than caring 🔹 Weak training and poor integration increase errors From our work in the healthcare field, our team knows the solution:  ✅ Workflows designed for elderly care ✅ Documentation that takes minutes, not 30 clicks ✅ Tools that support staff, residents, and families Within the next few years, we expect care homes that don’t adapt their EHRs will struggle not only with compliance but also with staff retention. If you’d like to know more, leave a comment below and we’ll reach out. #EHR #CareHomes #Pflegeheim #DigitalHealth #ElderlyCare #HealthcareInnovation

The future of U.S. home health care involves increased use of technology like remote patient monitoring and AI to create personalized care plans, a shift to value-based payment models, and greater access to care in home-based settings to meet the needs of an aging population. Key drivers include the aging population's preference for in-home care, the desire for personalized and holistic care, and payment reforms that reward better outcomes for patients

How can we help nurses on general wards identify deterioration earlier in increasingly complex patients? More insight at the bedside with NEWS2 scores and NIBP measurements in 15 seconds Time-saving workflows for more efficient observation rounds and patient management Hot and cold debriefing to improve the quality of CPR Centralised management - one hub for patient data for multiple departments. Find out more: https://lnkd.in/ekb__wuH Content intended for healthcare professionals only.

🔗 Interoperability Isn’t Optional in Value-Based Senior Care. What stood out most from this recent Skilled Nursing News article? This: “Your partner should bring the right technology to support value-based care—not require the facility to drive those changes alone.” 👏 100% agree. At AaNeel, we build systems that embed directly into ACO, I-SNP, and SNF workflows. Our platforms are CMS-aligned, interoperable, and designed for real-time data sharing across settings. 🧠 Read this sharp recap from the Skilled Nursing News RETHINK event: https://lnkd.in/ewVEpSGM #Interoperability #ISNP #ACO #SeniorCareTech #ValueBasedCare #CMS #AaNeel #HealthcareData