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Posted: January 14th, 2020

Streamlining Transition of Care Between Hospital and Skilled Nursing Facilities

Streamlining Transition of Care Between Hospital and Skilled Nursing Facilities

Transition of care is the process of moving patients from one setting of care to another, such as from a hospital to a skilled nursing facility (SNF). This process can be challenging and complex, as it involves coordination among multiple providers, communication of information, and management of medications, equipment, and services. Poor transition of care can lead to adverse outcomes for patients, such as readmissions, complications, errors, and dissatisfaction.

To improve the quality and safety of transition of care, several strategies have been proposed and implemented by various organizations and initiatives. Some of these strategies are:

– Using standardized tools and protocols to assess the readiness of patients for discharge and to communicate the essential information to the receiving facility. Examples of such tools are the INTERACT (Interventions to Reduce Acute Care Transfers) program and the SBAR (Situation, Background, Assessment, Recommendation) technique.
– Establishing collaborative relationships and agreements between hospitals and SNFs to facilitate the transfer of patients and the continuity of care. Examples of such agreements are the Preferred Provider Networks (PPNs) and the Bundled Payments for Care Improvement (BPCI) models.
– Providing education and training to staff and patients on the transition of care process and their roles and responsibilities. Examples of such education are the Project BOOST (Better Outcomes for Older Adults through Safe Transitions) and the Care Transitions Intervention (CTI).
– Implementing technology solutions to support the exchange of information and the coordination of care across settings. Examples of such technology are the electronic health records (EHRs) and the telehealth services.

These strategies have shown promising results in reducing readmissions, improving patient satisfaction, and lowering costs. However, there are still barriers and challenges that hinder the optimal transition of care between hospitals and SNFs. Some of these barriers are:

– Lack of alignment of incentives and accountability among different providers and payers.
– Variation in quality standards and expectations across settings.
– Limited availability and accessibility of resources and services in some areas.
– Cultural differences and communication gaps among staff and patients from diverse backgrounds.

To overcome these barriers, further research and innovation are needed to identify best practices and evidence-based interventions that can streamline the transition of care between hospitals and SNFs. Moreover, policy changes and system reforms are needed to create a more integrated and patient-centered care delivery model that can support seamless transitions across settings.


Coleman, E. A., & Boult, C. (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51(4), 556-557.

Hansen, L. O., Young, R. S., Hinami, K., Leung, A., & Williams, M. V. (2011). Interventions to reduce 30-day rehospitalization: a systematic review. Annals of internal medicine, 155(8), 520-528.

Ouslander, J. G., & Berenson, R. A. (2011). I need help writing my thesis Reducing unnecessary hospitalizations of nursing home residents. New England Journal of Medicine, 365(13), 1165-1167.

Tsilimingras, D., & Bates, D. W. (2008). Addressing postdischarge adverse events: a neglected area. The Joint Commission Journal on Quality and Patient Safety, 34(2), 85-97.


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