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 Continuing Care Leadership Coalition (CCLC), UHF is engaging 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 will address 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), will be encouraged. The initiative will also survey recently discharged patients and their family caregivers to better understand their experiences and identify common problems. 

To enhance the impact of the project, UHF will publish 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.

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 (Archcare)

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)

Contact: Joan Guzik