Improving Transitions of Care After Discharge from Skilled Nursing Facility

Use of skilled nursing facilities (SNF) as an intervening step in the transition from hospital to home is increasing among older adults. Evidence suggests that after hospital discharge, patients are at risk of adverse drug events, lost test results, Emergency Department (ED) visits and hospital readmissions. Patients who are discharged home from SNFs are generally more vulnerable to poor outcomes than patients who are discharged directly home. There is evidence that close follow up with the patient’s primary care provider (PCP) after hospital discharge is associated with lower 30-day readmission risk.