How to Prevent Hospital Readmissions in Senior Living Communities

Hospital readmissions are a significant concern for senior living communities. When a resident returns to the hospital shortly after discharge, it can disrupt their recovery, affect their quality of life, and create additional challenges for families, caregivers, and community teams.

EmpowerMe 360 takes a proactive, multidisciplinary approach to helping senior living communities prevent avoidable hospital readmissions. By bringing on-site therapy, care coordination, medical support and pharmacy services together within the senior living community, EmpowerMe 360 helps identify risks early, support residents through transitions in care, and address the clinical and functional factors that can contribute to another hospitalization.

Preventing hospital readmissions requires more than responding to a resident’s needs after a health crisis occurs. It requires a coordinated approach that supports residents before, during, and after significant changes in their health. From post-hospitalization therapy and medication management to fall prevention, chronic condition monitoring, and care coordination, senior living communities can take meaningful steps to reduce avoidable hospital visits and support better resident outcomes.

Hospitalization can be especially disruptive for older adults. Even when a resident receives appropriate treatment in the hospital, returning to their community may bring new challenges, including reduced mobility, medication changes, weakness, confusion, or difficulty following a new care plan.

Without appropriate follow-up and support, these challenges can increase the risk of complications and another trip to the emergency department or hospital.

Common factors that can contribute to hospital readmissions among older adults include:

• Medication-related problems
• Falls and injuries
• Worsening chronic conditions
• Infections
• Dehydration or malnutrition
• Difficulty following discharge instructions
• Lack of timely follow-up care
• Changes in mobility or functional ability
• Communication gaps between providers
• Cognitive changes or confusion

EmpowerMe 360 is designed to provide integrated healthcare services that address the root causes of hospital readmissions. By offering a daily on-site team, EmpowerMe 360 helps communities proactively manage resident health and prevent avoidable hospital stays. Key components of this approach include:

1. Prioritize Therapy and Rehabilitation

Post-hospitalization recovery is critical in preventing readmissions. EmpowerMe 360 provides on-site physical, occupational, and speech therapy, ensuring residents regain strength, mobility, and confidence after a hospital stay. These tailored therapy programs help residents achieve functional independence, reducing the risk of falls and other complications that could lead to rehospitalization.

2. Identify Changes in Health Conditions Early

Changes in a resident’s health condition can increase the risk of emergency room visits and hospital readmissions. EmpowerMe 360’s interdisciplinary team collaborates with senior living staff to help recognize changes in a resident’s condition, coordinate care, and support timely intervention. By identifying potential concerns early and connecting residents with the appropriate care and resources, communities can help reduce avoidable emergency room visits and hospital readmissions.

3. Improve Medication Management

Improper medication use is a leading cause of readmissions. Through integrated care coordination, EmpowerMe 360 works alongside community healthcare teams to ensure medication adherence, reduce adverse drug interactions, and educate residents on proper usage. This proactive approach decreases hospital visits related to medication mismanagement.

4. Implement Fall Reduction Strategies

Falls are one of the top reasons seniors are readmitted to the hospital. EmpowerMe 360 implements evidence-based fall reduction strategies, including balance training, environmental assessments, and mobility support. By equipping residents with the tools and knowledge to reduce fall risks, communities can maintain a safer environment and promote long-term well-being.

5. Strengthen Care Coordination and Communication

A key factor in preventing readmissions is seamless communication between healthcare providers, residents, and families. EmpowerMe 360 fosters collaboration among physicians, therapists, and senior living staff, ensuring that every resident receives continuous, coordinated care. Real-time updates, post-discharge follow-ups, and personalized health monitoring further strengthen the continuum of care.

Preventing hospital readmissions requires coordination across multiple areas of care. EmpowerMe 360 brings a multidisciplinary approach directly into senior living communities, helping address residents’ physical, functional, medical, and care coordination needs where they live.

The model combines an on-site team with therapy, medical support, and care coordination to create a more connected approach to resident wellness.

Through EmpowerMe 360, communities can access:

• Physical, occupational, and speech therapy to support mobility, function, cognition, communication, and recovery
• EmpowerMe Medical Group to provide access to physicians and nurse practitioners through telehealth
• Care coordination to help connect residents, families, community teams, and healthcare providers
• Pharmacy integration through EverSpring Pharmacy to support medication management and coordination
• Specialized dementia support to provide additional care for residents and their caregivers

Rather than waiting for a resident’s condition to worsen, the multidisciplinary team can help identify risks and opportunities for intervention earlier.

This integrated approach allows senior living communities to address multiple factors that can contribute to emergency department visits and hospitalizations.

A proactive approach to resident care can benefit more than just hospital readmission rates.

When residents receive coordinated support within their community, operators can also create a stronger overall care experience.

Potential benefits include:

• Reduced hospital and emergency department visits
• Better support following hospitalization
• Improved resident function and independence
• Greater confidence for residents and families
• More coordinated communication among care teams
• Improved staff efficiency
• Stronger relationships with healthcare providers and referral partners

EmpowerMe 360’s multidisciplinary approach has been associated with a 33% lower fall rate and a 43% lower emergency department visit rate than senior living averages*, highlighting the potential impact of proactive, integrated care.