Transitions from Skilled Nursing Facility to Home: Improving Quality and Patient Family Experience (Year 2)

Engaging eight skilled nursing facilities (SNFs) in the second year of a learning collaborative focused on developing and implementing interventions that better align with the needs of older, vulnerable patients and their family caregivers, resulting in patients being more prepared to return home following a stay in a SNF.

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 education, communication, or care coordination, or limited resources or social needs are not considered. During the first year of the learning collaborative, UHF helped the SNFs identify these gaps and conducted a patient and caregiver survey that provided more insight into the experiences of recently discharged patients and their caregivers around transitions of care. 

In the second year of this learning collaborative, the SNFs will focus on implementing interventions which prioritize the needs and preferences of the patient and caregiver and address patient, family, and staff communication about discharge planning and the transition home, care coordination, patient and caregiver education, and medication management. The SNFs will also collect data to measure the success of their interventions. To support these efforts, UHF has awarded $25,000 grants to each SNF. 

The participating facilities are listed below: 

  • Ferncliff Nursing Home and Rehabilitation Center 
  • Gurwin Jewish Nursing and Rehabilitation Center
  • Jamaica Hospital Nursing Home
  • The New Jewish Home, Sarah Neuman
  • Parker Jewish Institute for Health Care and Rehabilitation
  • Schulman and Schachne Institute for Nursing and Rehabilitation
  • Sea View Hospital Rehabilitation Center and Home 
  • Terence Cardinal Cooke Health Care Center 

The Transitions from SNF to Home Collaborative is made possible through support from Mother Cabrini Health Foundation. 

For more information on the Skilled Nursing Facility Learning Collaborative, click here.

Feb. 26, 2021
Number of Grantees
Focus Area
Quality and Efficiency