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: Hospital Onset Clostridium difficile infection (HOCDI) is one of the most common causes of hospital acquired diarrhea. As per a recent study, the mean healthcare costs attributable to primary Clostridium difficile infection (CDI) is about $24,205 per patient. This would be a lot more if the patients were to be discharged to skilled nursing [...]

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: Following hospitalization, a reported 20% of all Medicare patients are discharged to skilled nursing facilities (SNFs).  Sepsis was the cause of 25-68% of readmissions from SNFs based on a review of Medicare readmissions from patients at 96 SNFs in southeast Michigan. Sepsis is also the most common all-cause admission diagnosis and represents over $20 [...]

Background: Patients with a pre-existing diagnosis of advanced cancer who discharge to a skilled nursing facility (SNF) after an acute care hospitalization rarely receive future oncologic treatment, have high readmission rates, and minimal hospice use. We aimed to evaluate survivorship of patients discharging to a SNF with a new diagnosis of cancer based on their [...]

Background: After discharge from an acute care hospitalization, cancer patients may choose to pursue rehabilitative care in a skilled nursing facility (SNF). Our objective was to examine receipt of anti-cancer therapy, death, readmission, and hospice use of cancer patients who discharge to a SNF compared to those who discharge home or home with home health [...]

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: Older adults are commonly discharged to skilled nursing facilities (SNFs) after hospitalization. It is not known how patients anticipate SNF discharges and what they prioritize. The aims of this study are to explore what matters most to older adults during their hospital to SNF care transition. Methods: We conducted a grounded theory qualitative study. [...]