Heading Home from a Skilled Nursing Facility: Interventions and Tools for Improving the Transition

Transitions of care, when a patient moves from one care setting to another, are a vulnerable time. Inadequate preparation for transitions frequently places frail and otherwise 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.

To address the historically limited focus on transitions of care from a short-term stay in a SNF to home, United Hospital Fund launched a two-year learning collaborative with eight SNFs in the New York City metropolitan region with the support of the Mother Cabrini Health Foundation. This project’s primary purpose was to improve the quality of transitions for patients from skilled nursing facilities to home by engaging SNFs and the patients and family caregivers they serve. 

This report and toolkit provides a description of our learning collaborative approach, profiles several interventions undertaken by the participating facilities, and provides resources that can be useful to SNFs and other health care organizations as they focus on ensuring successful transitions to home for patients and their caregivers.