QI Initiative to Improve Transitional Care Processes Regarding Discharge from Skilled Nursing facilities

Best practice guidelines recommend that patients follow up with their primary care provider (PCP) within 1-2 weeks after discharge (DC) from skilled nursing facilities (SNFs). In a local safe transitions initiative with 25 SNFs, PCP appointment compliance within 8 and 14 days was 29% and 48% after SNF discharge. We delivered a quality improvement (QI) coaching intervention to enhance transitional care processes from SNF to community.