Transitions of Care:
From Hospital to SNF
Steven Tam, MD
Assistant Clinical Professor
UCI Program in Geriatrics, Internal
Medicine
Educational Objectives
Upon completion, the learner will be able to
1. Identify some of the potential problems in
transitional care involving hospital
discharges to Skilled Nursing Facilities
(SNF)
2. Describe the adverse outcomes of poor
transitional care
3. Will be introduced to writing proper
discharge orders to SNF
Potential Problems with transitioning
between Hospital and SNF
Breidenbach, Bob. (photographer). (2007). [photo]. The Providence Journal. Retrieved September
13, 2011 from http://shenews.projo.com/2007/11/indy-star-brady.html.
Potential Problems with transitioning
between Hospital and SNF

Communication
Between Hospital and SNF (and patient and
family)
 Between Personnel within each facility (shift
changes, and covering MDs)


Lack of Medication Reconciliation


Continue Home medications?
Which medications Stopped
Continuity of care (physicians, nursing
staff)
 Others?

Potential Problems with transitioning
between Hospital and SNF

Communication can be a problem with all hospital
discharges:



Studies show that hospital discharge summaries can
be lacking in information
Approximately 11% of discharge letters and 25% of
discharge summaries never reached the patient’s
PCP.
Important information to be communicated with the
SNF includes medications, functional level, weight
bearing status, follow-up plan

Lack of such information can lead to delays in care,
and other adverse outcomes.
Potential Problems with transitioning
between Hospital and SNF

Lack of Medication Reconciliation

Medication changes upon hospital admission
or discharge are a reason for adverse events.
 Prospective
study of 151 patients admitted to
general internal medicine, found that a regularly
used medication was discontinued in 46.4% of
cases
 In a study by Boockvar et al, adverse drug events
attributable to medication changes occurred in
20% of transfers between nursing homes and
acute-care hospitals.
Adverse Outcomes

Poor discharges can lead to:
Increased morbidity and mortality
 Hospital Re-admissions
 Higher costs
 Poor relationships between patients, families,
the skilled nursing facilities, the hospital and
professionals.

Adverse Outcomes

Transfers from SNF account for 8.5% of
Medicare admissions to acute care
hospital
40% of these hospitalizations occur within 90
days of SNF admission
 From Jenckes et al., close to 1/5th of all
Medicare beneficiaries discharged from
hospital are readmitted within 30 days

 Cost
= $17.4 billion in 2004; 26.9% due to heart
failure, 20.9% due to pneumonia
Proper Discharge Orders/Instructions
If not included in the discharge summary,
proper discharge orders/instructions
should accompany the patient to the SNF
 Necessary Elements include:

Legible Name (pager) of discharging MD, unit
 Legible care orders (such as for wound care,
lines)
 Reconciled medication list
 Diagnoses
 Follow-up plan

Discharge Orders/Instructions
Patient Discharge to Other Facilities
Instructions
Patient Name:
Medical Record Number:
Admission Date:
Discharge Date:
Discharge To:
Primary Diagnosis:
Onset Dates
Secondary Diagnosis:
Onset Dates
Procedures:
Dates:
Pertinent Studies (if not included in
DC summary)
Allergies:
Medications:
`
Discharge Orders/Instructions
Additional Medical Orders:
Physical Therapy: y/n
Physical Activity Level (weight bearing
status)
Occupational Therapy: y/n
Speech Therapy: y/n
Wound Care:
Line(s)/Foley Care:
Diet:
Red Flag Instructions:
Follow up Visits:
Pending Studies:
Advanced Directives (if not included
in DC summary):
CPR:
Tube Feeds:
Attending Physician at time of Discharge:
Further Hospitalizations:
Contact #:
Clinical Vignette

Now, look over the clinical vignette and
practice writing your own discharge orders
using the previous format!
References



Transitions of Care in the Long-Term Care Continuum.
Practice Guideline AMDA 2010
Boockvar KS, Fishman E et al. Adverse events due to
discontinuations in drug use and dose changes in
patients transferred between acute and long-term care
facilities. Arch Internal Medicine 2004; 164(5): 545-550.
Jenckes SF, Williams MV et al. Rehospitalizations
among patients in the Medicare fee-for-service program.
N Engl J Med 009; 360(14): 1418-1428.