When transitions from skilled nursing facilities to home are not well executed, elderly patients are at greater risk of poor outcomes. Creating safer and more effective transitions is essential for improving the well-being and experiences of these patients and their caregivers.

Why This Is Important

For elderly patients discharged from a skilled nursing facility (SNF) to home, transitions of care between settings can be perilous, placing frail and otherwise vulnerable older adults at risk of declining health, overuse of acute care services, social isolation, high levels of stress, anxiety, and dissatisfaction with care. For Medicare beneficiaries with multiple chronic conditions, lower socioeconomic status, dual Medicare/Medicaid eligibility, cognitive impairment, or limited English proficiency, the risk of poor outcomes is even higher.

Our Work

In partnership with the Greater New York Hospital Association (GNYHA), UHF engaged a group of New York SNFs in a learning collaborative to improve transition planning so that it better aligns with the needs and priorities of older, vulnerable patients and their family caregivers. The collaborative addressed problems with care coordination, continuity, communication, and medication management through interventions based on successful transitional models of care. Novel approaches that consider the needs and capabilities of patients and families, including social needs (e.g., housing barriers, food insecurity, or transportation), were encouraged during learning sessions that featured presentations from experts in the field. During the initiative, recently discharged patients and their family caregivers were also surveyed to better understand their experiences and identify common problems.  

To enhance the impact of the project, UHF has published reports on its findings, lessons learned, and recommendations for overcoming barriers to safe and effective transitions and improving the experiences and well-being of patients and families. The first report summarizes the findings of our survey of recently discharged patients and their family caregivers, and the second report is a toolkit that summarizes the SNFs transition improvement projects, their results, and a list of relevant resources.

SNF Learning Collaborative Participants

  • Ferncliff Nursing Home and Rehabilitation Center
  • 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
  • Terence Cardinal Cooke Health Care Center 

The Bottom Line

We know that transitions from SNF to home are complicated and a common pain point in the care of the elderly, especially for those with multiple chronic conditions. Patient and family caregiver insight into this process is key to improving the quality of transitions. 


Navigating Care Transitions From SNF To Home During a Pandemic—Lessons Learned
(Joan Guzik; Health Affairs Blog post, May 6, 2021)

Pain Points Along the Journey from Skilled Nursing Facility to Home: Patient and Caregiver Perspectives
(Pooja Kothari, Kevin Mallon, and Joan Guzik; UHF, November 2, 2021)

Heading Home from a Skilled Nursing Facility: Interventions and Tools for Improving the Transition
(Joan Guzik and Pooja Kothari; UHF, February 14, 2022)

Resources for Smoother Transitions
(webpage of resources accompanying the Heading Home toolkit and report; UHF, February 14, 2022)

Contact: Joan Guzik