Project 3: Transitions Out of the Hospital

One in four Medicare patients is discharged from a hospital to a skilled nursing facility (SNF); 25% of these patients are readmitted within 30 days.1 These readmissions cost Medicare $4.3 billion annually and increase patients’ risk of mortality.2 Previous research suggests that improving communication and collaboration among hospital and SNF providers may reduce readmissions and enhance the quality of care;3, 4 however, this area remains understudied. The primary aims of Project 3 are to reduce 30-day unplanned hospital readmissions and to improve the quality and safety of the transition process.

Process Analysis

Our team partnered with area SNFs and regional quality improvement efforts to work with the people most closely connected to the transition of care. The project sites included a 28-bed teaching service, a 14-bed general medicine hospitalist unit, and local skilled nursing facilities. We used purposeful sampling to identify participants with direct experience or in-depth knowledge of hospital discharges and SNF admissions, including leadership, frontline staff, and patients and caregivers. Our participants candidly discussed their successes and challenges with care transitions during data collection, and later reviewed and offered thoughtful feedback on our findings.

Our methods included:

  • Observations at all study units, targeted observations of staff at work, and attendance at biweekly safety conference calls
  • Qualitative interviews with hospital and SNF providers
  • Process mapping sessions with frontline staff from the hospital and SNFs
  • Case studies of recent readmissions from local SNFs
  • Focus groups with patients and caregivers at SNF study units
  • Quantitative data pulled from the hospital electronic medical record

Intervention Design and Development

Our participants emphasized the importance of communication and relationships between hospital and SNF providers. They called for accurately assessing and addressing patient needs and improving the quality of information exchanged during the transfer process.

The project team is working with hospital and SNF providers to develop pilot interventions. Current efforts focus on establishing a warm handoff between physicians and/or midlevel providers at sending and receiving facilities; including direct contact information for providers in transfer documentation; clarifying orders at the time of referral; and ensuring that patients have been engaged in a goals of care conversation before hospital discharge.

1 Krumholz HM, Nuti SV, Downing NS, Normand ST, Wang Y. Mortality, Hospitalizations, and Expenditures for the Medicare Population Aged 65 Years or Older, 1999-2013. JAMA, 2015. 314(4): p. 355-65.
2 Mor, V., Intrator, O., Feng, Z., Grabowski, D.C.: The revolving door of rehospitalization from skilled nursing facilities. Health Aff. (Millwood) 29(1):57-64, Jan.-Feb. 2010.
3 King, B.J., Gilmore-Bykovsky, A.L., Roiland, R.A., Polnaszek, B.E., Bowers, B.J., Kind, A.J., The Consequences of Poor Communication During Transitions from Hospital to Skilled Nursing Facility: A Qualitative Study. Journal of the American Geriatrics Society, 2013. 61(7): p. 1095-1102.
4 Shah, F., O. Burack, and K.S. Boockvar, Perceived Barriers to Communication Between Hospital and Nursing Home at Time of Patient Transfer. Journal of the American Medical Directors Association, 2010. 11(4): p. 239-245.

You really have to have a comprehensive continuity model that really builds on the strengths of different professions coming together in order to address all the dynamics of the patient. Otherwise you really haven’t solved anything.

Interview participant
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The Transition from the Hospital to the Skilled Nursing Facility

This process map illustrates the specific tasks, decisions, and challenges involved in the hospital discharge and SNF admission processes. It was created with frontline providers from sending and receiving facilities. This effort is believed to be the first time that anyone has examined the specific care transition from YNHH to SNFs.