Pain Points Along the Journey from Skilled Nursing Facility to Home: Patient and Caregiver Perspectives

The associated press release can be found here.

Transitions of care are a precarious time for patients and their caregivers, and especially so for frail elders living with chronic diseases and complex medical issues. Care transitions have received increased attention over the past decade; efforts to improve transitions have originated, for the most part, in hospitals and focused on patients being discharged to either a skilled nursing facility (SNF) or home. However, there has been less focus on the needs of patients who are being discharged home following a short-term stay in a SNF. 

Building on a longstanding commitment to improving care transitions for patients and family caregivers, and an interest in advancing solutions to common and persistent problems, UHF engaged eight SNFs in a two-year learning collaborative, supported by the Mother Cabrini Health Foundation. With a market research firm, UHF designed a survey of patients and family caregivers who had recently experienced a discharge to home from the participating SNFs. This report presents the responses and the surveys themselves, evaluating four domains related to the SNF stay: transition planning and patient preparation, patient education about medication, experience after discharge, and response and information about COVID-19.