Researchers offer tips to improve transitions from hospital to post-acute care

Hospital discharges to post-acute care (PAC) settings are becoming more common, particularly as the population ages. These patients aren’t ready to be discharged home but may not need the intensive care hospitals can provide.

However, an effective transition to skilled nursing facilities (SNFs) or home health care (HHC) requires caregivers on both sides of the interaction to work together, which often doesn’t happen, according to the authors of an Annals of Internal Medicine web exclusive published May 15. 

“Approximately one-third of adult inpatients are referred to PAC after hospital discharge,” wrote Christine D. Jones, MD, MS, and Robert E. Burke, MD, MS—both with the University of Colorado School of Medicine. “Patients transitioning from the hospital to PAC have higher readmission rates than patients discharged home, and evidence suggests that suboptimal care transitions play a significant role in these cases.”

The authors highlighted three reasons for this breakdown and offered potential solutions.

1.  Hospitalists may not understand the intricacies of the PAC settings their patients are heading to.

“Hospital clinicians may not be aware that SNF physicians are allowed up to 30 days to complete an initial patient evaluation, and that SNFs are only required to have a registered nurse available for 8 hours per day,” Jones and Burke wrote. “Thus, hospitalists may have unrealistic expectations about the degree of monitoring and management provided in these settings.”

The authors suggested hospitalists spend some time in both SNF and HHC settings during their training, which could help them understand how these PAC setups operate and the level of care they could reasonably be expected to provide. They also said hospital physicians should take more ownership of decisions regarding PAC referrals, rather than deferring to physical therapists or social workers.

2. PAC clinicians are sometimes given inadequate information.

The amount of information PAC providers require extends beyond a traditional discharge summary, the authors noted. These clinicians need to know about the goals of care; the reasons for existing lines and catheters being placed as well as their expected durations; contact precautions; and current cognitive and functional status.

Jones and Burke said an existing program which links hospital and PAC clinicians via a weekly videoconference has shown potential to address these communication gaps while also reducing 30-day hospital readmissions and SNF length of stay.

3. Hospitalists don’t get much feedback about how their patients fared in PAC.

Often a hospitalist doesn’t know what happened to a patient unless she is readmitted, the authors noted. By collaborating with PAC providers to review the cases of readmitted patients, clinicians from both settings could work to improve future care transitions. Burke and Jones said a weekly teleconference could again serve as the vehicle for this refinement.