Improving Transitions of Care between a Skilled Nursing Facility and Primary Care Providers

Abstract

The number of patients discharged to skilled nursing facilities (SNFs) after hospitalization continues to increase. Current research has focused on how to improve hospital to SNF or community transitions, with very few studies focusing on the transition from the SNF to the community. The purpose of this project was to identify whether the use of a standardized SNF discharge packet would improve the transfer of patient information between SNF and outpatient primary care providers (PCPs). Utilizing the Centers for Medicare & Medicaid Services guidelines, a standardized discharge packet was created for use at a suburban SNF in the Midwest. Participants in this project received rehabilitation services at the SNF and were discharged to the community, independent-living, or an assisted-living community and followed with a PCP at the university health system. The discharge packet was completed 24-48 hours prior to the patient’s discharge and sent to the care transition center within a university health system upon SNF discharge. The care transition center was then responsible for ensuring that a follow-up discharge appointment was made with the primary care provider with 14 days after SNF discharge and that the discharge paperwork was available for the primary care provider to review prior to the patient visit. Of the ten patients included in the QI initiative, sixty percent of patients were seen by their PCP within 14 days after SNF discharge. Only 10% of patients visited the ED or were hospitalized prior to their PCP follow-up. PCP’s contacted via survey agreed that the care transition center helped improve communication between providers, but noted that some pertinent patient information continued to be missing. Further inquiry into the current process of uploading patient information to the electronic health record is needed to ensure that discharge paperwork is present for providers to review prior to the patient follow-up. Keywords: transitions of care, care transitions, skilled nursing facility, and community