Background: Many patients continue their post-acute care in settings such as skilled nursing facilities (SNFs). One in four hospitalized Medicare patients are discharged to SNFs. These patients are generally the elderly or require more care than patients discharged home, placing them at greater risk of clinical decline and rehospitalization. Moreover, 25% of patients discharged to SNFs were readmitted within 30 days which costed Medicare $4.34 billion in 2006. In our intervention, patients discharged to one of six partner SNFs from two academic hospitals were reviewed weekly in a multi-disciplinary post-discharge video or telephone encounter that included medical and nursing leadership from the discussant SNF and a hospitalist from the hospital. The discussion reviewed the discharge medications, treatment plan, clinical status, and follow-up care of the patients. The intervention took place from July 2021 to December 2021.

Purpose: The aim of this intervention was to evaluate the impact of the program on improving the transition to the post-acute care setting from inpatient and reducing readmissions from SNFs. We believed that the communication enabled by this program would augment the written discharge summary and in turn reduce medical errors and improve provider satisfaction on the safety of the transition.

Description: Based on the discussion, hospitalists were asked to assess for clinically significant errors within the discharge summary. Errors were classified as errors of omission when important information was not included and errors of commission when there was conflicting or incorrect information. Hospitalists (n=10) and SNF providers (n=13) were then asked to complete a survey to assess the importance of the intervention in improving transitions of care and reducing readmissions. During the study, 548 hospital patients were discussed in a post-discharge virtual encounter. After the discussions, hospitalists completed 510 discharge summaries assessments, of which 18% had errors of omission and 6.8% had errors of commission. The errors were then classified into one of five categories to include medication reconciliation, patients baseline status or labs, post-hospitalization follow-up plans, goals of care, or post-hospitalization treatment plan. Within errors of omission, 63.04% were due to post-hospitalization follow-up plans and within errors of commission, 77.14% were due to medication reconciliation. A survey of participating hospitalists (n=6) on a Likert scale (1 strongly disagree; 5 strongly agree) indicated the intervention was thought to improve transitions of care (4.5, SD 0.6) although there was less certainty that it reduced readmissions (3.5, SD 0.8). This view was shared by medical and nursing leadership at the SNFs (n=8); 4.6 (SD 0.5) on improving transitions of care and 3.9 (SD 0.6) on reducing readmissions.

Conclusions: Hospitalist-lead virtual collaborative rounding with SNFs identifies clinically significant errors in discharge summaries and improves transitions of care. Post-hospitalization follow-up plans, and medication reconciliation are the most common sources of errors identified in discharge summaries. Virtual collaborative rounding improves hospitalists knowledge of SNF clinical capabilities and thus can bridge the gaps during the transition of patients to the post – acute care setting from the hospital.