Related Experiment Video
Updated: Mar 1, 2026

Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit
Published on: September 30, 2020
Partnerships in Transitions: Acute Care to Skilled Nursing Facility
Mae L Dizon1, Ruth Zaltsmann, Cheryl Reinking
1Mae L. Dizon, DNP, RN, NP, ANP-BC, is an adult nurse practitioner who has mainly focused on geriatrics. She is the nurse practitioner and coordinator for El Camino Hospital's NICHE (Nurses Improving Care for Healthsystem Elders) Program that aims to improve the care provided to older adults. In addition to this, Mae has been integral in the implementation of the Transitions of Care Program, concentrating on reducing avoidable readmissions for skilled nursing facilities. Ruth Zaltsmann, MS, RN, was an emergency department nurse before joining El Camino Hospital as a program manager to develop, implement, and manage the Transitions of Care Program. In addition, Ruth has spoken at many conferences and webinars focused on hospital transitions work, preventing readmissions, collaborative work within the health care environment, and Medicare's Bundle Payment Care Improvement Initiative (BPCI). Ruth currently serves as a BPCI Clinical Program Manager for Dignity Health and provides consulting services on the topic of health care changes to hospitals and physician groups in San Francisco, CA. Cheryl Reinking, MS, RN, NEA-BC, is currently the Chief Nursing Officer at El Camino Hospital in Mountain View, CA. Cheryl oversees 24 nursing departments as well as laboratory, pharmacy, respiratory care, and clinical nutrition. Cheryl has been in this role since 2013. Cheryl has served El Camino Hospital for the past 20 years in multiple roles including Vice Chief of Clinical Operations, Director, and Manager. In addition, Cheryl is a member of the Magnet committee, which was instrumental in assisting the hospital in achieving Magnet status in 2005, 2010, and a third designation on 2013. Cheryl was recipient of the Silicon Valley Women of Influence Award in 2013.
Purpose/Objectives:
Older adults, in particular those discharged to skilled nursing facilities (SNFs), are at high risk for readmission. As part of a multifaceted approach to reduce readmissions, a community hospital initiated a 3-prong approach (Collaboration, Communication, and Competency) and partnered with regional SNFs.
Primary Practice Settings:
El Camino Hospital, an independent, locally owned, not-for-profit district, acute care hospital in Northern California, and 11 participating SNFs in the same region.
Findings/Conclusions:
Collaboration: The combined leadership team developed a case report form and instituted regular reviews of 7-day readmissions. Communication: Standardized form for transferring patients to SNFs, form for transfer from SNF to emergency department, and consent form to enable SNFs to administer antipsychotic medications were developed. Regular phone and video conferencing between clinicians at the hospital and receiving SNF were instituted. Competency: Educational series to recognize and intervene to prevent readmission, and mutual exchange of best practices among hospital and SNF staff, were instituted. Continued work among ECH and the participating SNFs has improved the flow of information in both directions; favorable results from the broader study to reduce readmissions hospital-wide provide support for these efforts.
Implications For Case Management Practice:
Initiating collaboration with the SNFs is imperative in the changing health care landscape. Because of the complexity of the problem, acute care facilities and SNFs need to create a partnership to ensure smooth patient transition. Communication between care settings is essential in achieving optimum patient outcomes.
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