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Reduce Hospital Readmissions With Effective SNF-to-Home Transitions

Analysis  |  By Christopher Cheney  
   April 15, 2019

New data shows that patients discharged from a skilled nursing facility to home face the highest risk of readmission in the first two days after SNF discharge.

Efforts to reduce hospital readmissions should include effective SNF-to-home transitions and appropriate skilled nursing facility length of stay, new research indicates.

For hospitals across the country, readmissions have become a crucial metric with quality and financial dimensions. A hospital's readmission rate is a key indicator of care quality and the effectiveness of discharge planning. Since 2012, Medicare has been penalizing hospitals financially for readmissions linked to several targeted conditions such as pneumonia.

The new research, which was published in the Journal of the American Medical Directors Association, features Medicare claims data collected from more than 67,000 heart failure hospitalizations in which patients where discharged to a SNF then to home.

The research includes several key data points:

  • 24.2% of patients discharged from SNF to home were readmitted to a hospital within 30 days of SNF discharge
  • The risk of readmission was highest in the first two days after SNF discharge
  • Readmission risk declined with longer SNF length of stay

"Interventions to improve post-discharge outcomes have primarily focused on hospital discharge. This evidence suggests that interventions to reduce readmissions may be more effective if they also incorporate the SNF-to-home transition," the researchers wrote.

Improving SNF-to-home transition

To reduce hospital readmission, the SNF-to-home transition is likely crucial, according to the researchers.

"Heart failure patients discharged from hospital to SNF are more medically and functionally complicated than the overall Medicare HF population. … Therefore, patients discharged from SNF may benefit from discharge planning because during an SNF stay medications may be started or adjusted, diets may be monitored, and lab tests may be obtained, which may need post-SNF discharge follow-up," they wrote.

The lead author of the research, Himali Weerahandi, MD, MPH, told HealthLeaders the next step for investigators is to scrutinize the SNF-to-home transition.

"Given the importance the discharge process is for hospitalized patients, I believe this is also very important for patients who are discharged from SNF, particularly since they are likely to be frail or cognitively impaired, and thus more susceptible to issues that may arise during vulnerable transition periods. Given the high readmission rates we see with our study, our next steps are to go into SNFs to speak with providers, patients, and their caregivers to identify what the current discharge process is like at SNFs, and how it could be improved," she said.

Hospital discharge best practices could point the way to improving SNF-to-home transitions, said Weerahandi, an assistant professor in the Department of Medicine and Department of Population Health at NYU School of Medicine, New York.

When patients are discharged from hospital to SNF, ideally a medication reconciliation and discharge summary describing the hospital course should go with the patient to the SNF, and verbal hand-offs should occur from the physician and nurse at the hospital to their counterparts at the SNF. Likewise, a similar process should occur between the SNF provider and the primary care provider when the patient is ultimately discharged home," she said.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


Readmissions are a key financial and quality metric for hospitals.

New data shows that a quarter of heart failure patients discharged from a hospital to a skilled nursing facility then to home are readmitted to a hospital.

Best practices for the SNF-to-home transition are likely similar to the best practices of the hospital-to-SNF transition.

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