Leadership and frontline providers from area SNFs were invited to participate in case studies to explore the root causes of recent unplanned 30-day readmissions to the hospital. A multi-disciplinary research team traveled to more than 20 facilities to interview providers on-site and discuss readmissions and challenges with care transitions. The team adapted a tool from the Interventions to Reduce Acute Care Transfers (INTERACT) communication kit, a quality improvement program developed with support from the Center for Medicare and Medicaid Services (CMS).
These in-depth examinations revealed the decisions that SNF providers face and the underlying factors that may place patients at higher risk for readmission. The research team identified individual and organizational factors that may place patients at increased risk for readmission, including acuity of illness and the capability of each facility.