A SNF-based enhanced care program may help reduce 30-day readmissions

Background: The acuity of many patients recently discharged from an acute care facility is high. Some of these patients are being transferred to a SNF upon hospital discharge. Currently existing SNF care systems may not be prepared sufficiently for the challenges that arise with the admission of such patients to the SNFs after hospital discharge, resulting in readmissions.

Study design: Observational, retrospective cohort analysis.

Setting: Collaborative effort among a large, urban, acute care center, interdisciplinary clinical team, 124 community physicians, and eight SNFs.

Synopsis: In addition to standard care, the Enhanced Care Program (ECP) included a team of nurse practitioners participating in the care of SNF patients, a pharmacist-driven medication reconciliation at the time of transfer, and educational in-services for SNF nursing staff. Following introduction of the three ECP interventions, 30-day readmission rates were compared for both ECP and non-ECP patient groups. After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P less than .001). Multivariate analyses confirmed similar results. Major caveats include that this was a single-hospital study and that selection of the enrolled patients was not random, but rather, was determined by their primary care providers, potentially leading to some confounding.

Bottom line: For patients discharged to SNFs, an interdisciplinary care approach may reduce 30-day hospital readmissions.

Citation: Rosen BT et al. The Enhanced Care Program: Impact of a care transition program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities. J Hosp Med. 2017 Oct 4:E1-E7. doi: 10.12788/jhm.2852

Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.

Background: The acuity of many patients recently discharged from an acute care facility is high. Some of these patients are being transferred to a SNF upon hospital discharge. Currently existing SNF care systems may not be prepared sufficiently for the challenges that arise with the admission of such patients to the SNFs after hospital discharge, resulting in readmissions.

Study design: Observational, retrospective cohort analysis.

Setting: Collaborative effort among a large, urban, acute care center, interdisciplinary clinical team, 124 community physicians, and eight SNFs.

Synopsis: In addition to standard care, the Enhanced Care Program (ECP) included a team of nurse practitioners participating in the care of SNF patients, a pharmacist-driven medication reconciliation at the time of transfer, and educational in-services for SNF nursing staff. Following introduction of the three ECP interventions, 30-day readmission rates were compared for both ECP and non-ECP patient groups. After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P less than .001). Multivariate analyses confirmed similar results. Major caveats include that this was a single-hospital study and that selection of the enrolled patients was not random, but rather, was determined by their primary care providers, potentially leading to some confounding.

Bottom line: For patients discharged to SNFs, an interdisciplinary care approach may reduce 30-day hospital readmissions.

Citation: Rosen BT et al. The Enhanced Care Program: Impact of a care transition program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities. J Hosp Med. 2017 Oct 4:E1-E7. doi: 10.12788/jhm.2852

Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.

Background: The acuity of many patients recently discharged from an acute care facility is high. Some of these patients are being transferred to a SNF upon hospital discharge. Currently existing SNF care systems may not be prepared sufficiently for the challenges that arise with the admission of such patients to the SNFs after hospital discharge, resulting in readmissions.

Study design: Observational, retrospective cohort analysis.

Setting: Collaborative effort among a large, urban, acute care center, interdisciplinary clinical team, 124 community physicians, and eight SNFs.

Synopsis: In addition to standard care, the Enhanced Care Program (ECP) included a team of nurse practitioners participating in the care of SNF patients, a pharmacist-driven medication reconciliation at the time of transfer, and educational in-services for SNF nursing staff. Following introduction of the three ECP interventions, 30-day readmission rates were compared for both ECP and non-ECP patient groups. After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P less than .001). Multivariate analyses confirmed similar results. Major caveats include that this was a single-hospital study and that selection of the enrolled patients was not random, but rather, was determined by their primary care providers, potentially leading to some confounding.

Bottom line: For patients discharged to SNFs, an interdisciplinary care approach may reduce 30-day hospital readmissions.

Citation: Rosen BT et al. The Enhanced Care Program: Impact of a care transition program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities. J Hosp Med. 2017 Oct 4:E1-E7. doi: 10.12788/jhm.2852

Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.