Hospital readmissions continue to be a significant patient-safety issue that plagues the healthcare industry. Despite the U.S. Centers for Medicare & Medicaid Services (CMS) implementation of the Hospital Readmissions Reduction Program (HRRP) in 2012, the 30-day hospital readmission rate hovers around 14%, resulting in an average readmission cost of $15,200. Disjointed transitions of care, lack of patient engagement, and fragmented patient data across the care continuum are largely driving these costly hospital readmissions.

The United Hospital Fund (UHF), a not-for-profit organization that focuses on the quality, efficiency, and access to care, in collaboration with the Mother Cabrini Health Foundation, recently published results from a two-year study on transitions of care for one of the most vulnerable populations: patients receiving care in a Skilled Nursing Facility (SNF). The study, Heading Home from a Skilled Nursing Facility: Interventions and Tools for Improving the Transition, highlighted many strategies to improve transitions of care between the SNF and the patient’s home to help reduce readmission rates.

Patients in SNFs are typically dealing with chronic or terminal conditions and/or recovering from a medical condition after a hospital stay. These patients need round-the-clock care from teams of providers like doctors, nurses, occupational therapists, and physical therapists, and often have complex medication regimens to follow. According to CMS, less than 53% of patients are successfully discharged home or to their community-based service following a stay in a SNF. This number represents a staggering realization of inadequate, ineffective, and inefficient transitions of care for these high-risk patients.

I recently had the honor to sit down with one of the authors of the report, Joan Guzik, MBA, Director, Quality and Efficiency at UHF, to hear firsthand the rationale for the study, lessons learned, and how SNFs can be better equipped to support SNF patients transitioning back to their homes.

Patient Education, Medication Management, Connecting Patient Data

According to Guzik, the study was originally intended to consider what happens to patients after they return home from the SNF.

“The initial plan was to focus on interventions that connected recently discharged patients with their primary care and community-based organizations,” said Guzik. “However, as we got deeper into planning for the study, we realized there were more immediate and pressing opportunities for improvement within the four walls of the SNFs in terms of educating patients on their condition and medication in advance of their discharge.”

While the concept of patient education and medication management is a no-brainer, this is often a challenge for elderly patients in SNFs who are managing complex medical conditions and rely on family members to support their medical regimes at home. The study revealed that SNF discharges are often rushed, leading to inadequate, inconsistent preparations that ultimately leave the patient uncertain about managing their condition and medications at home.

What results did the study see from improved discharge processes, patient communication and education? Guzik explains.

“By implementing a discharge process that focused on better care coordination and ensuring patients were clear about their condition and medications, understanding of prescribed medications jumped from 57% to 98%, while understanding of medical problems and associated symptoms that may be experienced at home jumped from 70% to 93%.”

Another top priority is connecting patient data across acute and post-acute care settings to ensure care teams have a 360-degree view of the patient. Patients entering a SNF typically come into the facility with a long, complicated history of conditions and medications, and are cared for by numerous care providers and specialists. Regardless of whether the patient is entering the SNF or being discharged back home, care providers inside and outside the walls of the SNF are not alerted of the patient’s move across the continuum.

Guzik agrees.

“The lack of data following the patient across the continuum is a real gap. If the nursing homes or any providers have the capability to be better informed in real time about the patient’s medications and medical history, that would ultimately lead to higher quality care and help reduce readmissions after discharge from the SNF.”

Leveraging Data to Improve Transitions of Care

As the healthcare system transitions from fee-for-service to value-based care, Accountable Care Organizations (ACOs) and Health Information Exchanges (HIEs) are increasingly called upon to oversee the care of the patient and reduce costly fines for readmissions.

Bridging the communication gap from one care setting to the next is vital in supporting transitions of care, and ultimately reducing readmission rates. Often, care teams at a SNF may not be aware that a patient receiving treatment is part of an ACO under contract. This information may not come to light until days after their visit.

Closing the gap requires an effective solution that equips care teams with bridge alerts to notify care teams of the patient’s medical history upon arrival at the SNF. Putting pertinent patient data in the hands of the SNF care teams provides a 360-degree view of the patient, which leads to higher quality care while meeting value-based models that drive healthcare costs down.

Equally important, bridge alerts must be utilized upon the patient’s discharge from the SNF to help spark proactive communication from the patient’s PCP once the patient arrives at home. It should not be the patient’s responsibility to follow up with their PCP. Instead, the PCP should have the ability to receive automatic notification of their patient’s arrival as well as discharge from the SNF so they can coordinate the appropriate follow-ups to ensure the patient does not return to the hospital.


I am energized by the passion that Guzik and the United Hospital Fund offer to support smoother, more effective transitions of care for patients being discharged from SNF. These highly vulnerable patients deserve the education and communication needed to ensure they feel comfortable managing their condition and medication regimen upon arrival at home.

Further, all care teams responsible for the patient deserve to have vital data and alerts at their fingertips to improve the quality, safety, and efficiency of care, with the ultimate goal of keeping the patient home and out of the hospital.

About the Author


Ashley Wells joined Audacious Inquiry (Ai) as a Director in 2018 to help drive partner engagement and growth across state HIE deployments. Previously, she served as Director of Business Development at Leap Orbit and managed hospital outreach across Maryland and West Virginia for the CRISP HIE. Ashley has sixteen years of collective experience managing client relationships and consulting projects in the health IT space. In her spare time, she enjoys traveling, ballet and pickleball.