By Melinda Young

A major point of vulnerability at skilled nursing facilities (SNFs) is the high rate of readmission caused by errors and gaps in care — usually involving medication issues, according to the results of a recent study.1

“When medications aren’t continuously maintained across the transition of care, or when things get missed, that really ties back to the quality of the handoff between the hospital and [SNF] staff,” says Dori Cross, PhD, BSPH, study co-author and assistant professor in division of health policy and management at the University of Minnesota School of Public Health.

Inadequate communication and information-sharing contribute to poor care transitions, Cross notes.

“In a lot of cases, there’s a real lack of understanding of what that high-quality communication and information-sharing would even look like,” she says. “Our research has shown that as the hospital providers and discharge planners are getting patients prepared to go to the skilled nursing facilities, there’s not a real clear understanding of exactly what information is needed.”

Integration efforts can improve care transitions. “Integration efforts are really about wanting to improve the outcomes, reduce readmission, and have the patient stay comfortably while at the skilled nursing facility,” Cross says. “A lot of these integration efforts are about improving tactics, such as care pathways and information-sharing, but it’s also about relationships.”

Hospital case managers need to build relationships with SNFs to better understand and fulfill the SNF needs, she adds.

Cross and colleagues studied 487 SNF-hospital pairs and found informal integration was most common in 53.3% of pairs. They also noted 43% of the integrated pairs shared clinicians, and 36.5% shared care coordinators. Quality/safety activities were shared in 35.1% of pairs.

Cross and colleagues were careful not to describe optimal integration because there is not one optimal form. “There’s everything from leadership teams meeting together quarterly, to building shared pathways, to formal integration,” she explains. “Some pairs even have co-location or shared ownership with the SNF.”

A crucial aspect of the integration is the hospital sending timely information to the SNF to help provide smooth, continuous care at the point of handoff.

“Our research is showing that hospitals and SNFs are trying a lot of different things, but in some ways, the fact that they are trying multiple different things means they are not quite there yet,” Cross explains. “They’re still trying to find out what really builds that strength of relationship for integration.”

From a hospital discharge planner’s perspective, they need to clearly understand what their SNF counterparts need. They need to communicate patients’ behavioral health needs, medication and equipment needs, and other important items that would help eliminate gaps of care when the patient is discharged to the SNF.

“Discharge planners have a lot on their plates,” Cross adds. “For a successful handoff, there has to be nuanced understanding of the interdependence between the hospital and skilled nursing facility.”

Cross and colleagues found sites that shared clinicians communicated information faster and more completely.

“We think that shows a real investment, a real strength of relationship, if the hospital is placing clinicians on site, at that SNF, to bridge the handoff,” Cross says. “So much of integration is about a warm handoff and having people to bridge the gaps.”

Care coordinators shared by hospitals and SNFs are key to bridging communication between the sites, Cross says. They are part of the needed layers of integration. Hospital leadership, including case management, should be in lockstep with the SNF in what the shared care pathways look like and how the teams will support care on the ground.

“Any single strategy in isolation is unlikely to yield huge gains,” Cross explains. “There needs to be a layered, or bundled, [approach] to have the necessary investment to help build that relationship.”

The study was conducted to find out how hospitals and SNFs are improving transitions of care. Using shared care coordinators is one of the solutions they asked about, she notes.

“I think that there’s a need for both administrative and true operational alignment within those practices to get us where we want to be in terms of investing and integration,” Cross says. “Responsibility for the patient doesn’t end as soon as they leave the hospital’s doorstep. It is a continuum. Having an understanding of what happens to patients when they are discharged, knowing how to support them, and working with the skilled nursing facility is, to me, true operational alignment.”


  1. Burke RE, Phelan J, Cross D, et al. Integration activities between hospitals and skilled nursing facilities: A national survey. J Am Med Dir Assoc 2021 May 29;S1525-8610(21)00469-2. doi: 10.1016/j.jamda.2021.05.005. [Online ahead of print].