Individuals discharged from the hospital to skilled nursing facilities (SNFs) experience high rates of unplanned hospital readmission, indicating opportunity for improvement in transitional care.
Local physicians providing care in SNFs were not associated with the discharging hospital health care system. As a result, substantive real-time communication between hospital and SNF physicians was not occurring.
A multidisciplinary team developed and monitored implementation of the Health Optimization Program for Elders (HOPE) to improve patient transitions from acute hospital stay to SNFs.
The HOPE used a nurse practitioner (NP) to identify geriatric syndromes, set patient/caregiver expectations, assess rehabilitation potential, clarify goals of care, and communicate information directly to SNF providers.
The intervention was feasible, addressed unmet needs and errors in the SNF transition process, and was associated with lower 30-day readmission rates compared with concurrent patients not enrolled in the HOPE.
An NP-led hospital to SNF transitional care program is a promising means of improving hospital to SNF transitions.