Patient safety and quality of care are threatened when patients move from one setting to another, but there are strategies that can address those gaps in care. A recent report in the The Joint Commission Journal on Quality and Patient Safety addressed the risk, specifically in the transition of care from a hospital to a skilled nursing facility (SNF), noting that these transfers often are marked by delays in executing treatment plans and poor communication among providers. In addition, SNF clinicians often have the impression that hospital clinicians are unwilling to address errors or concerns after patients leave the hospital. The study notes that 23% of patients discharged from a hospital to a SNF will be readmitted to the hospital within 30 days. (The full study is available online at:

The report supports the fact that many hospital readmissions are driven by the SNF’s inability to properly care for the transferred patient, says Larry Burnett, RN, a principal with KPMG Consulting in Phoenix.

“If you have a patient who’s been well cared for by a hospitalist and staff who are familiar with the condition and ready to answer questions, it’s no surprise that when you transfer the patient to a facility without that physician support and knowledgeable staff, readmissions will occur,” Burnett says. “We see that a lot. The solution is coordination between acute care and post-acute care, particularly with finding the appropriate place for the patient to be transferred.”

The study notes that hospital clinicians often are challenged to find good discharge options.

“These providers often struggled to identify a safe, appropriate care setting for patients with complicated medical and psychosocial needs. They grappled with financial policies that limited the availability of services for patients, including payer sources and reimbursement rates,” according to the report.

Collaboration Is Key

“Respondents emphasized the importance of communication but encountered significant barriers when exchanging information, including hospital providers’ poor knowledge about SNFs, inaccurate and incomplete documentation, and work flow challenges,” the report states.

Cases involving tracheostomy and ventilator patients show how quality of care suffers in transitions, Burnett says. “The average length of stay in a hospital for trach and vent patients is about 28 days, and getting them to a skilled nursing facility is actually better for them. Studies show that if you don’t take the patient off the vent in about seven days, you’re not likely to get them off the vent for quite a while,” Burnett says.

“So, leaving them in a hospital in the ICU is not the best thing. You want to get them to a facility that can wean them off the vent, but if you don’t find the right kind of facility with the right skills and resources, they will be right back at your hospital,” he adds.

The study authors say hospitals, SNFs, and research programs must work across institutional silos to improve care and transitions.

“This could include establishing direct communication channels between sending and receiving providers, working collaboratively on care plans that follow the patient from hospitalization through community discharge, instituting tours or visiting rotations through healthcare institutions, and identifying opportunities for facilities to manage costs across the continuum of care,” the authors wrote.

Hospital-to-SNF transfers can be improved with strategies such as hosting an interactive demonstration of the electronic referral system, convening a multidisciplinary team to conduct root cause analyses of 30-day unplanned readmissions, administering a survey assessing SNF clinicians’ experiences with hospital discharges, and implementing a telephone report between hospital and SNF clinicians before patient discharge, the study suggests.

Case Management Problems

One challenge for hospitals is how to get physicians involved in a patient’s care after a transfer, Burnett says. The growing popularity of hospitalists complicates the issue, with up to 80% of patients in some acute care hospitals cared for by a hospitalist, Burnett says. “There’s a huge break in the system when you try to get the patient back under the care of a physician in the community,” he says.

“It’s important that the case management system include components that get the patient appointments with a doctor who understands the care they’ve received so far and can take over in a seamless fashion. That’s where people are getting tripped up on many occasions,” he adds.

In many cases, hospital physicians are skeptical of the SNFs that are available for patient transfer and with good reason, Burnett says. That doesn’t mean hospitals can absolve themselves of any responsibility for the quality of care after discharge, he says. Some hospitals are working with SNFs to improve their care, and Burnett says that, ultimately, is the best solution.

“It’s a long, slow, painful process for most healthcare organizations. But until we get that care redesign built up more and better physician coverage in these skilled nursing facilities, hospitals are still going to suffer with readmissions and poor outcomes,” Burnett says. “It is in their best interest to work with these downstream facilities to improve transitions and reduce these gaps in care.”