Navigating Care Transitions From SNF To Home During A Pandemic—Lessons Learned

Transitions of care have long been recognized as a vulnerable time for patients and their caregivers, particularly among the frail elderly with chronic diseases and complex medical issues. Various models of care and interventions have been deployed to improve transitions of care and reduce readmission when patients move from acute care to a skilled nursing facility (SNF) or to home.

Far less attention has been paid, however, to the process of preparing patients to transition from a short stay in a SNF back to their homes. National data from the Centers for Medicare and Medicaid Services reveal undeniable room for improvement, with only 50 percent of patients with Medicare Part A coverage successfully returning to home or community following a short stay in a SNF.

United Hospital Fund (UHF), a not-for-profit organization with a mission to build an effective and equitable health care system for all New Yorkers, recognized this gap and designed a project to engage eight nonprofit SNFs in a learning collaborative to address this issue. With the support of the Mother Cabrini Health Foundation (MCHF), and supplemented by UHF’s own grant making, UHF designed the collaborative as an opportunity to apply quality improvement (QI) approaches to problems that interfere with successful transitions and to assist the SNFs in designing and implementing interventions that could result in smoother transitions that respond to the needs, capabilities, and preferences of patients and their family caregivers.

According to the MCHF, “This research/learning project can ultimately improve care for older adults, which is a priority population for our foundation, by better preparing patients for return to home.”

The Project

In January 2020 we began our project journey—the first year was designed as a planning year focusing on recruitment of SNFs, design and delivery of the content (the virtual learning sessions), facility-specific problem identification, and planning of interventions. The second year was designed to refine and implement interventions, evaluate their impact, and disseminate results.

Shortly after we completed recruitment of eight SNFs for the collaborative in March 2020, New York experienced the initial onslaught of the COVID-19 pandemic. Arguably, the most severely impacted health care organizations were SNFs who care for some of the most vulnerable among us. As a result, our well-planned journey took unexpected turns and required mid-course corrections.

While we were able to adjust our timeline and delay the launch of the collaborative until late spring 2020, COVID-19 would continue to be the backdrop for our initiative and to affect our efforts in numerous ways. UHF awarded small grants to each SNF to support staff time and effort and other project-related costs, which enabled them to participate in the project during this difficult time. This model of making grants from our own endowment to augment external foundation support has been effective for UHF in implementing provider collaboratives over the past decade.


COVID-19 required that we shift the collaborative activities to a fully virtual format. During the first year, we held six learning sessions via Zoom and five coaching calls (also on Zoom) with each project team. We assisted the teams as they used process mapping and other QI tools to examine their discharge planning processes and workflows and identify root causes of problems and opportunities for improvement. Collaborative sessions provided content on evidence-based interventions and best practices, common “pain points,” available resources, and opportunities for peer-to-peer learning.

To provide the SNFs with information early in the project about actual transition experiences, UHF engaged a market research firm to conduct a survey of patients who were recently discharged from participating facilities, as well as their caregivers. Survey findings were consistent with gaps identified in the literature—there was not enough of the following: education regarding medications, identification of social needs and referrals to community-based organizations, understanding of and addressing of symptoms post discharge, and post-discharge follow-up.

For example, while 90 percent of patients surveyed indicated that they had felt prepared to go home, responses to specific questions indicated gaps in transition planning. Only 52 percent of patients responded that they had received information about symptoms and problems they may experience, and only 40 percent of patients surveyed stated that they had received help from the SNF in arranging an appointment with a primary care provider.

Furthermore, the survey results revealed that only 42 percent of patients and 42 percent of caregivers reported that they had received sufficient medication instruction while at the SNF. Findings were reviewed with the SNFs and used to inform intervention plans.

Specific interventions are focused around a few common areas:
•    Coordinating internal discharge planning activities and standardizing processes to ensure that patients’ needs are identified and addressed early in their stay and to enhance communication among patients, caregivers, and staff to minimize gaps in discharge preparation.
•    Developing condition-specific educational tools and medication regimen instruction so that patients and their caregivers understand how to perform care effectively following discharge and using teach-back techniques to assure understanding and address health literacy challenges.
•    Modifying post-discharge phone calls, an intervention essential to identifying transition issues and rectifying problems that may occur soon after the patient’s return to home.

Specific questions will also be added to post-discharge call scripts to assess the impact of the new interventions.

Challenges And Lessons Learned

Launching a new learning collaborative during a pandemic was challenging but also surprising in some ways. With the coronavirus spreading among nursing home residents and staff, frightfully scarce personal protective equipment (PPE), and nursing homes under the regulatory and media microscope, staff at the eight SNFs were still able to carve out time by June 2020 to focus on this initiative. The effort and commitment of the SNFs was remarkable and sufficient to make progress on tackling longstanding barriers to more effective transitions.

We quickly learned that to be successful, flexibility was key. For example, fewer short-stay discharges from the SNFs could have impacted our ability to obtain an adequate survey sample size. We tackled this by delaying the survey until summer 2020, when discharges began to increase; adding an additional “wave” to the survey; and using a multimodal approach (paper, online, and phone) to reach as many patients and caregivers as possible.

Visitation restrictions at the SNFs posed special challenges and demanded alternate ways to engage and prepare caregivers for the discharge of their family member. We recognized that these restrictions would likely impact the experiences and views of caregivers and, thus, our survey results.

We also learned that each SNF was unique and that staffing, quality capacity, and other resources, including technology, vary considerably. Addressing the extraordinary challenges of COVID throughout the project has required that we tailor expectations for each SNF and balance competing priorities at each. Our coaching calls were extremely helpful in better understanding the specific situations at each SNF and helping each one to make progress on the collaborative goals.

While we had hoped that some of the interventions would focus on strengthening relationships with community-based organizations for patients with unmet social needs, we found that the participating SNFs preferred to focus instead on improving their internal processes.

To foster peer-to-peer learning, a key component of a successful collaborative, we designed interactive exercises and modified them for use in a virtual environment, but then we encountered a bit of a digital divide across the SNFs. In addition, our participants did not know each other in advance of the collaborative and did not have the benefit of more casual opportunities for the communication and sharing that are typical of a prepandemic, in-person learning collaborative. Despite these barriers, we succeeded in building strong relationships with the SNFs, and over time the staff at participating SNFs became more comfortable sharing with their peers.

In 2021 the SNFs will be implementing and evaluating their interventions. Metrics will include process and outcome measures to assess the results of facility-specific interventions as well as overall project impact. We are excited about our ongoing journey to help the SNFs build their own capacity to continuously improve care transitions, and we look forward to supporting their individual and collective efforts on behalf of patients being discharged to home and the family members who care for them.

For more information, see Skilled Nursing Facility Learning Collaborative—Smoothing the Path from SNF to Home.


Joan Guzik, "Navigating Care Transitions From SNF To Home During A Pandemic—Lessons Learned," GrantWatch section of Health Affairs Blog, May 6, 2021, Copyright © 2021 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.


May 6, 2021
Focus Area
Quality and Efficiency
Quality Institute