Collaboration on Skilled Nursing Transitions Reduces 30-Day Readmissions

A collaborative initiative between nurse practitioners (NPs), doctors, and other medical staff to help patients discharged from a hospital to a skilled nursing facility lowered 30-day hospital readmissions.

The Enhanced Care Program fosters collaboration between medical staff and patients in settings where nurse practitioners were available around the clock; medication reconciliation procedures were also followed at the time of transfer, and the program included educational in-services for SNF staff, in addition to standard care.

Bradley Rosen of Cedars-Sinai in Los Angeles, along with his colleagues, conducted an observational, retrospective cohort evaluation between Jan. 1, 2014, and June 30, 2015, to see if the program reduced 30-day hospital readmissions. The researchers found that, after adjusting for sociodemographic and clinical characteristics, the patients in the intervention group who received care under the enhanced program were 29% less likely to be readmitted to the hospital within 30 days than those in the control group were.


The findings come as the SNF Value-Based Purchasing model is slated to take effect starting this October. Under that new structure, SNFs automatically lose 2% of their Medicare funding, which can be earned back by hitting certain quality benchmarks. And the 30-day readmission rate is a crucial metric under this new model.

SNFs have been getting calls for some time to improve their care-transition performance to both improve patient experience and avoid costly rehospitalizations. At the American Health Care Association’s (AHCA) annual convention in Las Vegas, Kimberly Green, COO of the Edmond, Oklahoma-based Diakonos Group, LLC, said the best SNFs should have staff at the hospital before a resident is even released. And several post-acute care providers have begun to take steps to keep better track of their patients, with the goal of keeping them from returning to the hospital.

The patients in the Cedars-Sinai study included all patients discharged from Cedars-Sinai Medical Center to eight partner SNFs that were eligible for participation, according to the study abstract.


The findings were published in the Journal of Hospital Medicine.

Written by Maggie Flynn

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