UHF Releases Report and Toolkit to Help Skilled Nursing Facilities Improve Patient Transitions from Inpatient Care to Home

NEW YORK, NY—February 14, 2021—United Hospital Fund today released a report and toolkit that contains a variety of resources designed to help skilled nursing facilities (SNFs) and other health organizations ease the transition from inpatient care to home for both patients and their family caregivers. 

The report and toolkit grew out of UHF’s SNF Learning Collaborative, a two-year partnership with eight skilled nursing facilities in the New York metropolitan area working to improve care transitions. In November 2021, the Collaborative released the results of a survey of the SNFs’ patients who had been discharged, as well as family caregivers, to identify the concerns of the people most affected by the transition. 

The new report and toolkit, titled Heading Home from a Skilled Nursing Facility: Interventions and Tools for Improving the Transition, highlights promising interventions implemented by the facilities to improve transitions. 

Transitions of care, when a patient moves from one care setting to another, are always a vulnerable time for patients, and particularly for frail elderly patients with multiple chronic conditions. Inadequate preparation for transitions frequently places vulnerable older adults at risk of overuse of acute care services, declining health, permanent residency in a skilled nursing facility (SNF), and high levels of stress, anxiety, and dissatisfaction. According to the Centers for Medicare & Medicaid Services, less than 53 percent of patients successfully return to their home or a community-based service following a short stay in a SNF. 

During the UHF Collaborative, several interventions implemented by participating SNFs produced meaningful improvements. For example, when staff stepped up efforts to explain medications, patient understanding of their prescriptions increased from 57 percent to 98 percent, while patient understanding of symptoms and problems they may experience once home increased from 70 percent to 93 percent.

“As the population ages and the prevalence of chronic disease rises, safe, effective, and person-centered transitional care plans will become even more essential,” said Joan Guzik, UHF director of quality and efficiency, Quality Institute, and lead author of the toolkit. “The SNF interventions implemented in our project, and explained in the toolkit, led to marked improvement in our partners’ ability to ensure that patients’ needs were met as they went home.”

The toolkit provides a description of proven interventions and resources that can be useful to SNFs and other health care organizations, including a reference library. Also included are potential areas of focus for future work by care providers, policymakers, and other stakeholders.

The SNFs participating in the collaborative vary greatly in terms of size, location, communities served, and resources; as a result, their areas of focus and their solutions to problems were varied as well. However, communication breakdowns, lack of standardized discharge planning processes, and inadequate patient and family education were problems common to all at the start of the project. The SNFs were able to identify opportunities for improvement in their internal discharge planning processes that can be beneficial to many facilities and are shared in the toolkit. Among them:
•    The value of mapping out the discharge process to identify opportunities for improvement
•    Standardizing processes 
•    Increased participation of staff across disciplines and ensuring that all staff communicate clearly and consistently in a way that patients and families can understand
•    Early and tailored follow-up phone calls after discharge

However, the report noted that systemic challenges must also be addressed if the quality of care for older adults going home from a skilled nursing facility is to improve.

“More attention and resources are needed to support our long-term care infrastructure in the United States, including both facility-based care and home- and community-based services,” said UHF president Anthony Shih, MD. “The difficulties that patients experience when transitioning home from care in a skilled nursing facility are an example of where targeted improvement efforts can make a difference. UHF has a longstanding interest in and commitment to improving transitions of care.” 

In addition to Ms. Guzik, the toolkit was co-authored by Pooja Kothari, Consultant at X4 Health and formerly with UHF. This work was supported by the Mother Cabrini Health Foundation. The report and toolkit can be downloaded without charge at UHF’s website here

About United Hospital Fund
United Hospital Fund works to build an effective and equitable health care system for every New Yorker. An independent, nonprofit organization, we are a force for improvement, analyzing public policy to inform decision-makers, finding common ground among diverse stakeholders, and developing and supporting innovative programs that improve health and health care. We work to dismantle barriers in health policy and health care delivery that prevent equitable opportunities for health. For more on our initiatives and programs, please visit our website at www.uhfnyc.org and follow us on Twitter.