Background: Post hospital discharge review during the transition from hospital to skilled nursing facility (SNF) is critical to avoid medication errors, improve patient outcomes and reduce hospital readmissions (1-3). Despite increased integration of electronic health records (EHR) across health entities, communication gaps and discharge-related medication errors still persist (2,4). These challenges can be more predominant […]

Background: Post hospital discharge review during the transition from hospital to skilled nursing facility (SNF) is critical to avoid medication errors, improve patient outcomes and reduce hospital readmissions (1-3). Despite increased integration of electronic health records (EHR) across health entities, communication gaps and discharge-related medication errors still persist (2,4). These challenges can be more predominant […]

Background: Errors in medication reconciliation frequently occur at transitions of care. Patients discharged to skilled nursing facilities (SNFs) are particularly vulnerable to the consequences of these mistakes. An interprofessional team at UVA Health implemented a longitudinal quality improvement (QI) project to reduce medication reconciliation errors for patients discharging from acute care medicine services to SNF. […]

Background: Following a hospitalization, older adults, their caregivers, and clinicians caring for them face a complex decision regarding post-acute care (PAC). The purpose of PAC, delivered by a skilled nursing facility (SNF) or home health (HH), is to support the recovery of patients after hospital discharge. However, the transition to PAC is a vulnerable time […]

Background: The VA, like many health care systems, seeks to meet the needs of a rapidly growing older adult population. The transition from hospital to post-hospital care – particularly in older adults- is increasingly common, but unfortunately is high-risk and low-value. Further, 85% of older adults choosing a skilled nursing facility had a higher-quality facility […]

Background: At our institution, an interprofessional (IP) hospital team consisting of a hospitalist, pharmacist, and nurse practitioner, meets with IP teams from local skilled nursing facilities (SNFs) in a weekly teleconference to discuss patients recently discharged from the hospital to the SNFs. The purpose is to identify and reconcile gaps in care during patients’ transitions. […]