Transitioning patient care between hospitals and skilled nursing facilities (SNFS) brings many challenges.  Patient and family anxiety, unfamiliarity and even misinformation about SNFs increase the opportunity for unsatisfactory outcomes and readmissions to the hospital..  Previous research has demonstrated frequent and potentially harmful medication discrepancies during hospital to nursing home transitions, and low frequency of hospital follow up recommendation completion. 


Despite a lack of definitive research, quality improvement methodology is being used to find new means of improving care for these patients.  We designed an intervention at our institution aimed at improving the transitions from our academic center to SNFS with the hopes of reducing readmissions. 


The HOPE intervention consists of a consultation prior to discharge by a Nurse Practitioner (NP), working with Geriatric Medicine Specialists, and post-discharge follow-up by the NP at approximately 72 hours. Patient referrals come from the General Medicine service with a comparison group of general medicine patients who were discharged to skilled nursing facility during that time period without a HOPE consultation.    The HOPE consultation consists of a chart review, medication review, patient history and examination, and patient/family discussion regarding diagnosis, prognosis, rehabilitation potential and goals of care.  A post-discharge follow-up is then done within 72 hours after discharge. The Nurse Practitioner either makes a post-discharge follow up phone call or a visit to the SNF.  The post-discharge follow-up encompasses a review of high risk and new medications, inquiry about rehab participation and the status of follow-up appointments. Additional elements include a discussion of outstanding symptoms/issues identified in the hospital or developing since discharge to the SNF and recommendations which are discussed with the SNF provider and nursing staff.  Readmission rates are being monitored to guide the development of the program. The content of the post-discharge follow-up is captured to identify opportunities for program enhancement.


Between May 2016 and September 2016, 118 patients received HOPE Consults.  Readmission rates for the intervention group have not been lower than the overall readmission rate for the overall general medicine service. 

The follow up phone calls and SNF visits by the NP have been valued by patients, families and SNF staff.  There were 50 follow up encounters (visit and phone call).  Recommendations were made 54% of the time; 44% of these were medication recommendations and 56% non-medication recommendations. 20% of the follow-ups uncovered missing information on follow up appointments (e.g., location, time, not scheduled). Medication discrepancies were found in 4 of the 50 encounters.

The HOPE consult post-discharge follow-up is identifying transition issues that may impact avoidable readmissions such as medication-related problems and problems with follow up appointments.  At this time, we have not yet identified a reduction in readmission rates from SNFs, however, there appears to be value as perceived by patients, families and SNF staff.