Medicare spent $25 billion on patient care at skilled nursing facilities in 2023, where, to qualify for coverage, a patient must need daily skilled nursing or rehabilitation services.

Hospital readmissions from these facilities have long remained at a fairly consistent rate of 20%-25% within a 30-day window, which represents a significant challenge for patients, healthcare systems, and payers alike. Unplanned returns to the hospital occur for a variety of reasons and can indicate gaps in care coordination, patient monitoring, or discharge planning while placing vulnerable populations — including older adults, those with complex medical conditions, and members of marginalized communities — at a greater risk for poor outcomes.

High readmission rates also carry financial implications: In 2021, the Government Accountability Office reported that Medicare spent over $5 billion on readmissions in 2018, and patients may also incur additional costs for care.

At the American Public Health Association’s 2024 Annual Public Meeting and Expo, a team of public health experts led by Karl Minges, PhD, MPH, from the University of New Haven, West Haven, Connecticut, presented a study on skilled nursing facility (SNF) interventions to reduce 30-day readmission rates. It showed the apparent effectiveness of interventions focused on specific patient populations, collaborative interventions with hospital care teams, and quality care models.

The study also reported that interventions using a multifocal approach with evidence-based strategies to address clinical, operational, and systemic factors can improve care transitions, enhance patient safety, and optimize health outcomes while lowering costs.

Albert Ogannisyan, RN, clinical researcher, and the founder of HealthBridge Global Institute, based in Auburn, California, said that these issues are a priority for both the hospitals and skilled nursing facilities that he works with.

“Readmissions are viewed as a shared responsibility by efficient hospital,” he said. “They collaborate and employ a standardized root cause analysis approach. Both parties may address the underlying problem rather than merely the symptoms by monitoring trends over time, such as if inadequate medication reconciliation is the primary cause of the majority of readmissions.”

Strengthening Care Transitions and Communication

Ogannisyan alludes to the fact that communications are key in every partnership between a hospital and an SNF, especially when it comes to care transitions, one of the trickiest points in a patient’s healthcare journey. He said that the hospitals and SNFs he works with make the exchange of information and working together to coordinate care their top priority.

A real-time discharge checklist is used by the hospitals that are successful, he said. Until the discharge report is electronically transmitted to the SNF, transport is not planned. The nursing staff completes the medication reconciliation at the patient’s bedside, and once the patient comes, SNF personnel confirms it. Additionally, a transitional care coordinator fills in any gaps and confirms that papers have been received.

This article details a Harvard study that found worse patient care outcomes as hospital shifts change. The research team behind that study later expanded their work to discover declines in care at transitions from ambulatory facilities to the hospital, all based on critical information about the patient’s condition, medications, or treatment plans being lost or miscommunicated.

This lack of clarity then led to medication errors, delayed treatments, or worsening of the patient’s condition. The system that the Harvard team developed is now trained at the I-PASS Safety Institute and is extensively documented on their site, where extensive I-PASS resources are offered. Ogannisyan said the hospitals he works with make structured communications like this a top priority, and that a direct link between the transferring facility and the receiving facility is imperative.

Standardized tools such as SBAR — Situation, Background, Assessment, Recommendation — can ensure that hospitals provide comprehensive information to skilled nursing facilities upon transfer. Electronic health record integration between hospitals and nursing facilities also supports seamless data sharing, giving SNF clinicians immediate access to discharge summaries, lab results, and care plans, he said.

“Regular interdisciplinary care team meetings — including nurses, physicians, therapists, and social workers — are essential to ensure everyone is aligned on the patient’s needs,” Ogannisyan said. “Establishing direct communication channels between SNFs and hospitalists or primary care providers can also reduce readmissions by allowing timely clarification of care instructions and rapid response to emerging issues.”

Comprehensive Medication Management

A study published in the February 2020 issue of the Journal of the American Association of Nurse Practitioners discussed how medication errors affect hospital readmissions, as also noted by the Harvard team. Polypharmacy, drug interactions, and incorrect dosages can result in adverse events that lead to hospitalization, particularly among older adults with multiple chronic conditions.

Study investigators Rachel Anderson, DNP, from Ardent Healthcare in Lynchburg, Tennessee, and Rita Ferguson, PhD, RN, clinical assistant professor in the College of Nursing at The University of Alabama in Huntsville, designed an evidence-based workflow process for systematic medication reconciliation.

A full-time NP then put the workflow process into practice to complete stabilization visits on each facility admission at a 90-bed SNF over a 30-day period. As a result, hospital readmissions were reduced by almost 30% in their sample population.

Pharmacists can also play a crucial role in reviewing medication lists for potential interactions or duplications. Engaging consulting pharmacists for regular medication reviews can help identify unnecessary or high-risk drugs and support deprescribing initiatives.

Additionally, educating patients and their families about medications — including their purpose, dosage, and potential side effects — empowers them to play an active role in preventing complications. Technology solutions, such as electronic medication administration records, can be used as a backstop to reduce errors and provide real-time alerts for missed doses or contraindications.

Other Steps to Reduce Risk and Create Lasting Change

Certain patients are inherently at higher risk for readmission due to factors such as advanced age, multiple comorbidities, cognitive impairment, or limited social support. Honing in on a way to accurately identify those patients, however, has proven difficult.

Telehealth technology and remote patient monitoring can enhance surveillance, particularly for patients with chronic diseases such as heart failure or chronic obstructive pulmonary disease. For example, daily weight tracking for heart failure patients allows staff to detect fluid retention early and adjust treatment before hospitalization becomes necessary.

Ogannisyan said that telehealth monitoring can be an asset in communications between hospitals and SNFs. “Secure direct messaging, shared dashboards with real-time clinical warnings, and even telehealth rounding — in which hospitalists electronically check in on high-risk SNF patients — have all produced positive outcomes for the hospitals we collaborate with.”

He said hospitals that have made the most progress in reducing readmission rates from skilled nursing facilities have dedicated clinicians following up on patients admitted to the nursing facilities he works with. Long-lasting change comes by ensuring that these tasks are carved out on a permanent, dedicated basis, rather than assigning them as what he termed “extra duties,” he said.

“The difference depends completely on dedicated resources. Some institutions make hospitalists available for SNF case consultations by assigning them to their post-acute partner networks,” Ogannisyan said. “Others integrate liaisons or nurse navigators to facilitate communication between the SNF and the hospital. Weekly reviews of high-risk cases and on-site training for SNF employees are common tasks for quality assurance consultants.”