UHF Survey Highlights Patient, Caregiver Perspectives on Transitions from Skilled Nursing Facilities to Home

Two-thirds of both patients and caregivers said they needed more help understanding medications; patients were rarely asked about social needs

NEW YORK, NY—November 2, 2021—A United Hospital Fund report released today reveals that a majority of surveyed patients who were sent home after a short stay in a skilled nursing facility said they received and understood discharge instructions, but still reported some substantial gaps in preparation and care coordination—gaps that can worsen outcomes for frail patients. 

The results of the survey were summarized in the UHF report, Pain Points Along the Journey from Skilled Nursing Facility to Home: Patient and Caregiver Perspectives.

According to the Centers for Medicare & Medicaid Services, only 50 percent of patients covered by Medicare Part A successfully return to their home or community following a short stay in a skilled nursing facility (SNF). Working with a market research firm, UHF surveyed 263 patients discharged from eight New York-area nursing homes, rehabilitation centers, and other skilled nursing facilities (SNF), as well as 249 family caregivers. 

On the positive side, over 80 percent of patients reported that they received and understood discharge instructions, and more than 70 percent said they obtained needed services after discharge, including medications, equipment, and additional help. Some 75 percent of patients reported that home care services were delivered on time. These results indicate that SNFs are carrying out essential components of discharge planning effectively. 

However, performance fell short in other areas. The survey found that at least two-thirds of both patients and caregivers said they needed more help understanding medications and assistance with side effects. Patients were rarely asked about concerns related to social needs such as food, housing, transportation, and affordable care. Even when asked, close to half of those in need were not referred to services to help mitigate those concerns. 

In addition, patients and caregivers reported that follow-up appointments with primary care providers or specialists were arranged less than half the time. More than 40 percent said they did not receive a follow-up call after they were discharged.

“Transitions of care are a precarious time for patients and their caregivers, and there has been limited focus on the needs of patients who are discharged to home following a short stay in a skilled nursing facility,” said Joan Guzik, director of Quality and Efficiency at UHF and a co-author of the report. “This survey highlights a sizeable opportunity for quality improvement efforts.”

In 2020, building on a longstanding commitment to improve care transitions for patients, UHF partnered with eight skilled nursing facilities in a two-year learning collaborative, supported by the Mother Cabrini Health Foundation. UHF surveyed the eight facilities’ patients and family caregivers who had recently been discharged to home in order to identify pain points in the process from the perspectives of the people most affected. 

From August to December 2020, patients who had been discharged with the past six months, as well as family caregivers, were contacted by phone, mail, and email. The UHF report presents the responses and evaluates four areas related to the SNF stay: transition planning and patient preparation, patient education about medications, experience after discharge, and response and information about COVID-19.

These results were shared with the SNFs, which used them to inform efforts to improve the discharge process. These efforts will be profiled in a subsequent report.

“Transitions in care put patients and their caregivers at risk of not only high levels of stress, anxiety and social isolation, but also of poor health outcomes including avoidable readmissions. Those outcomes are even more likely for patients with multiple chronic conditions, lower socioeconomic status, cognitive impairment, or limited English proficiency,” said Anthony Shih, MD, UHF president. “Our survey provides crucial insights to our SNF partners to help them mitigate those outcomes, which in turn will help create a more effective and equitable health system.”

Along with Ms. Guzik, the survey report was written by Pooja Kothari, former senior program manager for UHF; Kevin Mallon, UHF program analyst; and Lynn Rogut, former director of quality and former team lead for quality and efficiency for UHF. The report was supported by Mother Cabrini Health Foundation. The full report and results can be downloaded from 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


Nov. 2, 2021
Focus Area
Quality and Efficiency
Quality Institute