Hospitalists Improving Transitions of Care Through Virtual Collaborative Rounding with Skilled Nursing Facilities-the HiToC SNF Study.

ABSTRACT:

Background

Over one in five Medicare patients discharged to skilled nursing facilities (SNFs) are re-hospitalized within 30 days of discharge. Poor communication between the hospital and SNF upon hospital discharge is frequently cited as the most common cause of readmission.

Aim

The goal of this program was to assess the ability of a weekly post-discharge hospitalist led virtual rounding program to augment the written discharge summary sent to SNFs.

Setting

Two academic hospitals and six SNFs in Baltimore, MD.

Participants

Hospitalists and medical directors or directors of nursing from the partner SNF.

Program description

During weekly encounters, the hospitalist and SNF providers discussed the clinical status, discharge medications, treatment plan, and

SUBMITTER: Kuye IO 

PROVIDER: S-EPMC10713912 | biostudies-literature | 2023 Dec

REPOSITORIES: biostudies-literature