Decreasing Readmissions Through Transitional Care from SNF to Home
Hospitals and skilled nursing facilities (SNFs) are financially pressured to decrease patient readmission rates. Transitional care—from hospital to home or hospital to SNF—is typically effective for patients with chronic conditions. However, it is rarely implemented for patients discharged from SNF to home.
Presenters at the Conference conducted a cohort study using patients discharged from one of three local SNFs. A total of 135 patients participated in the study; 55% of them were female, the average age was 72 years, and the average Charlson comorbidity index (CCI) index was 2.27. Starting November 2014, patients being discharged (n = 50) were offered a home visit by a physician or nurse practitioner if they lived within half an hour of the SNF. They also received 7-, 15-, and 30-day phone calls to assess needs. Patients were then followed for 30 days to determine readmission rates to the local hospital compared to patients discharged who did not have home visits or calls. For the intervention group, medication errors and physician orders were tracked. There were no significant differences between the intervention and comparison groups regarding age sex, number of medications, or CCI.
They found that the 30-day readmission rate dropped from 13.1% to 4% in the intervention group, with no significant differences in rates based on sex; however, there was a trend for greater readmission rates in patients with higher CCI and greater age. In the intervention group, 17 patients (34%) had 25 medication errors identified and corrected, and 13 patients (26%) required new physician orders during the home visit.
The presenters felt that the results from this study were encouraging although the data was not statistically significant; home visits conducted by practitioners and phone calls can identify issues that can be corrected and can decrease readmission rates of patients discharged from SNFs. They suggest that transitional care from SNFs to home should be further investigated as a way to decrease readmission rates.
