Transitions from Skilled Nursing Facility to Home: Improving Quality and Patient Family Experience

To improve the quality of patient care transitions from skilled nursing facilities to home or community-based settings through a learning collaborative that engages eight facilities in developing expertise in designing transition plans that better align with the needs of older, vulnerable patients and their family caregivers, resulting in patients being more prepared to return home to the community.

Improving transitions of care is a critical challenge for health care organizations today. For frail elderly and chronically ill patients returning to the home and community, transitions in care may pose problems and risks. Despite staff efforts to ensure a safe discharge home, discharge plans may not fully meet the needs of patients and family caregivers if there are gaps in communication or care coordination, or limited resources or social needs are not considered. A learning collaborative will address problems with care coordination, continuity, communication, and medication management, and approaches that consider the needs and capabilities of patients and families will be encouraged.

Each skilled nursing facility was awarded a grant of $25,000 to support their activities. Project goals across the SNFs focus on implementing best practices in care transitions, understanding and acting on patient and caregiver needs and preferences, enhancing training and education for patients and caregivers, and coordinating with medical and community-based social service providers to better support patients and caregivers in the community. Participating facilities:

  • Ferncliff Nursing Home and Rehabilitation Center (ArchCare)
  • Gurwin Jewish Nursing and Rehabilitation Center
  • Jamaica Hospital Nursing Home
  • The New Jewish Home, Sarah Neuman, Westchester
  • Parker Jewish Institute
  • Schulman and Schachne Institute for Nursing and Rehabilitation
  • Sea View Hospital Rehabilitation Center and Home (New York City Health + Hospitals)
  • Terence Cardinal Cooke Health Care Center (ArchCare)

These grants are made possible through support from Mother Cabrini Health Foundation. For more information on these grants and the Skilled Nursing Facility Learning Collaborative, click here

April 1, 2020
Number of Grantees
Focus Area
Quality and Efficiency