Background: Many patients continue their post-acute care in settings such as skilled nursing facilities (SNFs). One in four hospitalized Medicare patients are discharged to SNFs. These patients are generally the elderly or require more care than patients discharged home, placing them at greater risk of clinical decline and rehospitalization. Moreover, 25% of patients discharged to [...]

Background: Overuse of daily labs (DL), especially CBC and BMPs in hospitalized patients leads to increased costs and utilization of resources, iatrogenic anemia, and patient discomfort. Prior quality improvement (QI) efforts in hospital medicine have worked to reduce excessive lab utilization, but few have focused on labs ordered on the day of discharge (LOD) . [...]

Background: Over 5 million hospital-to-skilled nursing facility (SNF) transitions occur annually. Of these patients, 20% are readmitted within 30 days, and 25% of those readmissions are deemed preventable. While effective communication between the inpatient clinician and the accepting SNF clinician has been shown to improve re-hospitalization rates, few studies have examined clinician confidence or competence [...]

Background: The current process of transitioning to a skilled nursing facility (SNF) is non-transparent and inefficient. For patients and caregivers, the process is stressful and confusing. For the providers and the hospital, it could result in lower patient satisfaction and increase patient length of stay. For SNF administrators, it often causes a mismatch of patient [...]

Background: Nursing facility (NF) quality of care is the subject of many innovations. The Centers for Medicare and Medicaid Services (CMS) allows for public comparison of quality measures. New Mexico (NM) consistently explores how to improve care in these areas. There are 70 NFs in NM; half are scattered in isolated rural areas. The shortage [...]