The Care Transitions Nurse in a Skilled Nursing Facility

Our aim is to improve care transitions for older adults discharging from an acute hospitalization to a skilled nursing facility for sub-acute rehab by creating a role of a Care Transition Nurse to review every admission to our facility. Improvement in care transitions is important because it affects rehospitalization, medication errors and grievances. The target population is adults being discharged from the hospital to sub-acute rehab. Measurable goals include 30 day hospitalization rates, medication errors and grievances with/without a Care Transition Nurse.