1. Dizon, Mae L. DNP, RN, NP, ANP-BC
  2. Zaltsmann, Ruth MS, RN
  3. Reinking, Cheryl MS, RN, NEA-BC


Purpose/Objectives: Older adults, in particular those discharged to skilled nursing facilities (SNFs), are at high risk for readmission. As part of a multifaceted approach to reduce readmissions, a community hospital initiated a 3-prong approach (Collaboration, Communication, and Competency) and partnered with regional SNFs.


Primary Practice Settings: El Camino Hospital, an independent, locally owned, not-for-profit district, acute care hospital in Northern California, and 11 participating SNFs in the same region.


Findings/Conclusions: Collaboration: The combined leadership team developed a case report form and instituted regular reviews of 7-day readmissions. Communication: Standardized form for transferring patients to SNFs, form for transfer from SNF to emergency department, and consent form to enable SNFs to administer antipsychotic medications were developed. Regular phone and video conferencing between clinicians at the hospital and receiving SNF were instituted. Competency: Educational series to recognize and intervene to prevent readmission, and mutual exchange of best practices among hospital and SNF staff, were instituted. Continued work among ECH and the participating SNFs has improved the flow of information in both directions; favorable results from the broader study to reduce readmissions hospital-wide provide support for these efforts.


Implications for Case Management Practice: Initiating collaboration with the SNFs is imperative in the changing health care landscape. Because of the complexity of the problem, acute care facilities and SNFs need to create a partnership to ensure smooth patient transition. Communication between care settings is essential in achieving optimum patient outcomes.