Using the 5Ms Framework to Optimize Hospital-to-SNF Care Transitions

All training programs for both undergraduate and graduate medical education include rich exposure to the hospital and clinic environments. The level of exposure to community-based care settings such as skilled nursing facilities is much more variable, potentially leading to gaps in knowledge related to the dynamics of transitional care in these settings. Moreover, about 20% of hospital stays end with a discharge to a SNF, which means that medical students, residents, fellows, and attending physicians may be routinely discharging patients to a health care setting where they themselves have never practiced (J Am Med Dir Assoc 2021;22:2496–2499).