Transitional care following a skilled nursing facility stay: Utilization of nurse practitioners to reduce...

This quality improvement project's goal was to identify older adults who were at high risk for readmission following a skilled nursing facility (SNF) admission and evaluate the impact of a nurse practitioner (NP) visit within 72 hours of SNF discharge. The aims of this project were to reduce 30-day readmissions, identify gaps in care, and address care needs for patients recently discharged from a SNF. High readmission risk was estimated through use of readmission risk prediction and frailty tools. Results of the project revealed several gaps in care including medication discrepancies, delays in start of home health services, and lack of follow up with a primary care provider. Of the patients seen for a transitional care visit (TCV), none were readmitted. Project findings indicate there is value in seeing patients in their home soon after SNF discharge. Further work is indicated to improve care transitions in this area.