Background: 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 problem: 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.
Methods: 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.
Interventions: 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.
Results: 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.
Conclusions: An NP-led hospital to SNF transitional care program is a promising means of improving hospital to SNF transitions.