Table 2

Preventability of readmission and factors contributing to readmission

n=128SNF providers (n, %)Hospital providers (n, %)
Preventability of readmission
 Not preventable102 (79.7)75 (58.6)
 Potentially preventable24 (18.8)46 (35.9)
 Preventable2 (1.6)7 (5.5)
Did the patient have a clinical condition(s) that clearly required the patient to be cared for in an acute setting?
 Yes112 (87.5)111 (86.7)
 No16 (12.5)17 (13.3)
If the patient’s readmission was known 24–48 hours beforehand, was there anything that could have been done differently that might have prevented the readmission from occurring?
 Yes26 (20.3)38 (29.7)
 No97 (77.6)90 (70.3)
 No response7 (5.47)0 (0.0)
Could better, proactive, timely communication with the clinical team (moonlighter, covering MD, RN, therapist, and so on) as well as acute care clinical stakeholders (ED, consultant, PCP, surgeons) have possibly prevented this readmission from happening?
 Yes9 (7.0)18 (14.1)
 No112 (87.5)110 (85.9)
 No response7 (5.5)0 (0.0)
Factors contributing to readmission
 No contributing factors51 (39.8)16 (12.5)
 Issues with goals of care planning or end-of-life management9 (7.0)18 (14.1)
 Outpatient treatment coordination5 (3.9)3 (2.3)
 Family unprepared for transition to SNF or requested transfer8 (6.3)1 (0.8)
 Medical complexity4 (3.1)16 (12.5)
 Patient discharged too soon from hospital*9 (7.0)13 (10.2)
 Unnecessary for ED to admit patient to acute care3 (2.3)6 (4.7)
 Failure or delay in diagnosis/treatment at SNF2 (1.6)11 (8.6)
 Patient admitted to wrong level of care1 (0.8)0 (0.0)
 Patient non-adherent to medical treatment2 (1.6)2 (1.6)
 Issues with communication with acute care team2 (1.6)5 (3.9)
 Unnecessary transfer to ED/acute care2 (1.6)2 (1.6)
 Medication/pharmacy related1 (0.8)11 (8.6)
 Other†33 (25.8)38 (29.7)
 No discharge summary at time of admission to SNF or lack of accurate discharge summary0 (0.0)6 (4.7)
  • *Included only in second iteration of data collection (64 of 128 patients) and percentages are not representative of entire sample.

  • †Included two falls at SNF, four Foley catheter-related infections and one suboptimal monitoring of oral intake at SNF.

  • ED, emergency department; MD, medical doctor; PCP, primary care provider; RN, registered nurse; SNF, short-term nursing facility.