EXECUTIVE SUMMARY

A study from Mount Sinai Health System in New York City revealed that 25% of patients who were transitioned to a skilled nursing facility (SNF) returned to the hospital within 30 days. The organization employed case management solutions to achieve a 20% reduction in the 30-day readmissions from SNFs.

• Case managers assist SNF patients with medication reconciliation and pharmacological updates.

• They also ensure patients schedule a follow-up appointment with a primary care provider within 14 days of the SNF discharge.

• The care management team obtains a copy of the SNF discharge paperwork and sends it to the primary care provider.


Mount Sinai Health System in New York City found that one in four patients in an accountable care organization (ACO) transitioned to a skilled nursing facility (SNF) returned to the hospital within 30 days. To fix this problem, the organization focused on case management solutions that also work in hospital settings.

“We asked, ‘What are the best practices we do in our hospital when we discharge patients?’ We can use those best practices for skilled nursing facilities,” says Esther Moas, MS, RN, senior director of care continuum at Mount Sinai. “We already have a lot of work we’re doing to prevent 30-day readmissions from the hospital. This work was to prevent high readmission rates after discharge from the skilled nursing facility, too.”

For instance, SNF patients need medication reconciliation and appropriate pharmacological updates before patients receive their prescriptions.

Case managers can ensure patients schedule a follow-up appointment with a primary care provider within 14 days of the SNF discharge, Moas says. “We also set up a process where our care management team gets a copy of the SNF discharge paperwork and sends it over to the primary care provider,” she explains. “We update physicians on any changes, whether it’s the acute care or SNF setting.”

They write a summary of why patients went to the SNF, what the goals were, and whether the patient is achieving those goals.

With those changes, the organization achieved a 20% reduction in SNF 30-day readmissions, Moas says. “The results have continued,” she adds. “The most recent data are showing even better numbers.”

Medicare incentivizes SNFs and hospitals to reduce their readmissions. This helped with buy-in, Moas notes. “The penalty went into effect after we started the model,” Moas says.

“We have quarterly meetings [with stakeholders], where we present data and have collaborative leadership,” Moas continues. “We have shoutouts where facilities that are doing exceptionally well get a shoutout from the group, and we give them a certificate to display to patients.”

The idea is to keep all partners aligned in improving readmission rates. “We do a lot of work to keep it exciting for everyone,” Moas says.

There always will be some facilities that are indifferent, but most want to work with case management to improve care coordination processes, she adds. “We’re up to 30-plus facilities committed to working with us,” she says. “We’re a huge system. Overall, facilities are really interested in how they can partner and build closer collaborations with us.”

The case management success derives from following basic principles of discharge planning and ensuring patients are linked to appropriate community resources, Moas says.

“We applied those inpatient best practices and moved them forward, sharing what we do on discharge planning,” she says. “We also asked, ‘Where are some of the areas on the hospital side where we wish we could do more upon discharge?’”

For instance, some patients are in the hospital for too brief a stay for case managers to solve their most pressing social determinants of health problems.

“We cannot resolve their homelessness and food insecurity issues in a way that would have a long-term effect on them, so we do referrals to community-based organizations,” Moas says. “Then, we paused and said, ‘Patients that go to SNFs are captured there for over a week, and sometimes for three weeks or up to 30 days,’” Moas explains. “We started to work with the SNF social worker on the housing and transportation needs that we identified when they were inpatients.”

For example, case managers could work with a patient’s family to remove bedbugs from the patient’s home while the patient is at the SNF, she says.

“We realized we could do a lot more and a better job while the patient is at the skilled nursing facility, receiving rehab,” Moas says. “We follow up on patients after they transition back to the community.”

Case managers can help patients and families outfit their homes with shower bars, ramps, and motorized chair stairs. “We can refer the family to multiple vendors, and have the vendors come into the home,” Moas says. “All those things take time, and impact a patient’s long-term success at home.”

Case managers also consider patients’ financial needs and long-term planning. “We say, ‘If you could afford private care for the next few weeks, what will happen after that if you want the care to be ongoing?’” Moas says. “We work with patients when they need resources to complete the application for Medicaid.”

When patients are discharged from SNFs, their community issues often go unaddressed, and the patient is not prepared to go home, Moas explains. “You sent them to a SNF because the home environment is not safe for them due to new right-sided weakness,” she says. “But the SNF did not set up the patient’s home environment to be safe for when the patient is discharged.”

This is where case managers can help to get the home environment safer. “Following through with patients has made the best difference,” Moas says.