Patients discharged to a skilled nursing facility (SNF) are at significantly higher risk of readmission within 30 days. For hospitalists at the Cleveland Clinic, the rate in 2012 to date is 25.8%. The physician communication during this transition for the patient can be suboptimal because of poor understanding of the reality of care in both directions.


To quantify where there is a gap in perception during this transition of care and to build common solutions to improve the handoff.


In both the spring and fall of 2012, a group of both hospitalists and SNF physicians agreed to meet and begin building a collaborative partnership to identify best practices in patient transition from hospital to SNF. The process began with a survey that was sent out to both hospitalists and SNFists (Figs. 1 and 2). The purpose was to identify gaps in expectations from each provider group. These examples show a wide disconnect between the perception of quality of information provision from the hospitalist and the SNFist. As a result of these findings, the Department of Hospital Medicine brought together hospitalists and SNF doctors who accept many of the patients we discharge to skilled nursing facilities for 2 “summits,” each 3 hours long. This Long‐Term Care Leaders Summit had several key questions. What key elements would be included in a discharge summary designed specifically for patients discharged to a SNF? There is a mismatch in patient/family expectations that can lead to readmissions. What strategies can we employ — from both ends — to level‐set expectations? How do we prioritize which follow‐up appointments need to occur while still in the skilled facility, and which can wait until after discharge? Given new regulations for prescriptions, especially schedule II prescriptions, how can we most quickly assure patients get needed medications on transition? How can we maximize use of newly hired midlevel providers in SNFs in this transition process? How can we improve the admission process for all involved?


Bringing together all key participants to meet and work out ways to improve handoffs provided numerous benefits. Besides helping each side to understand their peers' work flows, it also allowed us to humanize those we don't directly work with. Through direct dialogue, we are now developing a “transition bundle” of care to be done for each patient discharged by a ospitalist to a SNF.

Figure 1.Comparison of survey results of Cleveland Clinic Medicine Institute (MI) hospitalists and SNF providers regarding completeness of information provided.

Figure 2: Comparison of survey results of Cleveland Clinic Medicine Institute (MI) hospitalists and SNF providers regarding accuracy of medication reconciliation.