Background: Patients with complex health and behavioral needs often face barriers to securing long-term care (LTC) placements. A busy acute care hospital within a large public healthcare system frequently experienced capacity strain due to the high volume of such patients requiring LTC. To address these challenges, the hospital formed a partnership with a skilled nursing facility (SNF) within the same safety net network that had deep experience in managing behaviorally complex patients. This collaboration—between two facilities, each with over 800 beds in an urban setting—aimed to streamline transitions, reduce prolonged hospitalizations, and improve placement efficiency. It focused on patients hospitalized on medical-surgical units who faced barriers to acceptance at other SNFs, including prior behavioral disturbance, psychiatric comorbidities, substance use disorder, criminal justice involvement, and/or insurance issues.
Purpose: The initiative sought to improve the referral and placement process between the acute care hospital and the SNF through regular case conferences and enhanced communication. The primary goals were to reduce Alternate Level of Care (ALC) inpatient days and increase placement rates to the SNF.
Description: Between April and October 2025, a series of case conferences were held in which the hospital’s inpatient team presented 17 long-stay, behaviorally and medically complex patients who had been rejected by other SNFs. Case presentations followed a standardized framework developed by the SNF, which included detailed clinical, psychiatric, and behavioral histories (Figure 1). Of the 17 patients reviewed, 11 were successfully discharged to the SNF, 1 was preliminarily accepted and awaiting an appropriate bed, 1 was preliminarily accepted but later withdrawn after family elected for home discharge, and 4 were declined due to smoking or forensic history. Among the 11 transferred, the mean hospital length of stay prior to discharge was 351 days (median 287; range 92–1,012). On average, 270 of those days were ALC (median 132; range 0–957), representing 2,965 total ALC days transitioned to lower levels of care. The mean time from case conference to discharge was 44 days (median 28; range 2–160), reflecting efficient coordination between hospital and SNF teams. A readmission safety protocol ensured rapid return for any patient whose condition deteriorated after transfer. This protocol was used once, when a patient developed acute psychosis 13 days post-transfer and required re-hospitalization before eventually being discharged home to family.
Conclusions: This collaborative case-conferencing model between an acute care hospital and a SNF demonstrated the effectiveness of multidisciplinary collaboration within a unified safety net healthcare system. The initiative’s success was driven by several key factors: the SNF’s well-established protocols and expertise in managing behavioral complexity; use of a standardized, one-page template that enabled efficient information-sharing; and the trust built between teams, which fostered open communication, smoother decision-making, and greater efficiency. Together, these elements streamlined LTC placements, alleviated hospital capacity strain, and created a sustainable pathway for patients with complex needs.
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