Mapping the care transition from hospital to skilled nursing facility

Care transitions between hospitals and skilled nursing facilities (SNFs) are often associated with breakdowns in communication that may place patients at risk for adverse events. Less is known about how to address these issues in the context of busy patient care settings. We used process mapping to examine hospital discharge and SNF admission processes to identify opportunities for improvement.

A quality improvement (QI) team worked with frontline staff to create a process map illustrating the sequence of events involved with hospital discharge and SNF admission. The project was completed at an academic medical centre and two local SNFs in the north-eastern United States. Participants represented the care management, medicine, nursing, admissions, and physical therapy services. The data informed hospital QI interventions seeking to improve the quality and safety of hospital-SNF transfers and reduce unplanned hospital readmissions.

The final process map highlighted numerous activities that need to be coordinated between care teams, including the time-sensitive exchange of clinical and administrative information. Participants shared insights about how care teams reach critical decisions about patient disposition and post-acute care utilization.

Process mapping highlighted specific opportunities for improving communication between care teams. Participants advocated for earlier assessments of patients' functional status and support systems, including reliable at-home services. They also reasoned that improved communication would help patients and providers reach decisions together, coordinate work efforts, and better prepare for hospital discharge and SNF admission. This information can be used to improve patient care transitions between hospitals and SNFs.