Lessons Learned When Discharging Older Adults to Skilled Nursing Facilities

Area of Science:

• Healthcare quality improvement
• Patient safety in transitions of care

Background:

• Effective communication during patient transitions from hospital to skilled nursing facilities (SNFs) is vital for continuity of care.
• Inadequate transfer information can compromise patient safety and the quality of care provided in SNFs.

Purpose of the Study:

• To identify deficiencies in hospital-to-SNF transfer documentation.
• To understand the impact of incomplete information on SNF patient care.

Main Methods:

• Review of hospital-to-SNF transfer records.
• Surveys and interviews with SNF staff regarding their experiences with patient transfers and documentation.

Main Results:

• Four critical areas of documentation errors were identified: medication reconciliation, medication instructions, inpatient course/diagnoses, and follow-up care instructions.
• These errors complicate patient transitions and introduce safety risks for both patients and healthcare providers.

Conclusions:

• Enhancing education for hospital providers on discharge documentation is essential.
• Systemic and structural changes are needed to minimize human error and improve efficiency in the hospital-to-SNF transfer process.