30-day readmissions for patients at skilled nursing facilities (SNF) are common and preventable. We implemented a readmission review process for patients readmitted from two SNFs, involving an electronic review tool and monthly conferences. The electronic review tool captures information related to preventability and factors contributing to readmission. The study included 128 patients, readmitted within 30 days from 1 October 2015 through 1 May 2017, at a tertiary care academic medical centre in Boston, MA, and two partnering SNFs. There was a discrepancy in preventability rating between SNF and hospital reviewers, with 79.7% of cases rated not preventable by the SNF, and 58.6% by the hospital. There was moderate positive correlation between the hospital’s and SNFs’ preventability ratings (rs=0.652, p<0.001). In most cases, the SNF reviewers felt that no factors contributed (57.8%), and hospital reviewers felt that issues with end-of-life planning (14.1%) and medical complexity (12.5%) were major factors. Despite the lack of strong correlation between SNF and hospital responses, several cross-continuum quality improvement projects were developed. We found that implementation of a SNF readmission review process employing bidirectional review by SNF and hospital was feasible, and facilitated systems-based improvement in the transition from hospital to postacute care.
- hospital medicine
- healthcare quality improvement
- transitions in care
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Contributors MLM and KB take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: MY, CTP, MLM, AS, JS, LH, KB. Study implementation: MLM, JS, LH. Acquisition of data: EF, JS, LH. Analysis and interpretation of data: CIM, MLM, KB. Drafting of the manuscript: MY, JD, CTP, MCC, EF, CIM, AS, MLM, JS, LH, KB, MAH. Critical revision of the manuscript for important intellectual content: MLM, JS, LH, KB. Statistical analysis: MCC, CIM, MLM. Administrative, technical or material support: KB. Study supervision: KB.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement There are currently no unpublished data available. The published data presented have been deidentified. Unpublished data contain PHI and cannot be shared.
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