Improving Hospital-to-Skilled Nursing Facility Transitions: Resident-Led Implementation and Evaluation of an...

Each year, millions of patients are discharged from hospitals to skilled nursing facilities (SNFs), with about one in four Medicare beneficiaries requiring SNF care. These transitions are vulnerable to communication failures, and resident physicians who prepare discharge summaries receive limited training in SNF transitions, leading to inconsistent and incomplete information for receiving clinicians.

In September 2023 a resident-led team surveyed internal medicine residents (n = 53) and SNF providers (n = 11). Two thirds of residents felt confident in SNF documentation, and 61.2% in verbal handoffs, but fewer than half were comfortable counseling patients about SNF expectations. SNF providers cited limited clarity on pain management, wound care, and follow-up plans.

The authors developed an electronic health record (EHR)-embedded SNF discharge checklist prompting inclusion of key handoff elements, including medication changes, wound care, catheter management, and follow-up plans. Implementation strategies included education, reminders, and small incentives. Pre- and postintervention surveys were analyzed using a partially paired t-test (Looney and Jones method) to account for matched and unmatched respondents.

From October 2023 to May 2024, checklist utilization rose from 41% to 88%. Postintervention surveys showed significant improvements in resident confidence in verbal handoffs, medication communication, wound care, and catheter management. SNF providers reported improvements in understanding newly started medications, wound care, and analgesic plans, though medication continuation decisions and patient counseling about SNF transitions remained areas for growth.

A resident-led, EHR-integrated discharge checklist improved communication consistency and resident preparedness for SNF transitions, demonstrating the potential of structured documentation tools to support safer post-acute care transitions.