Can We Avert Hospital Readmissions from Skilled Nursing Facilities?

Approximately 20% of hospitalized older patients (age, ≥65) are discharged to skilled nursing facilities (SNFs), with nearly one quarter of those patients rehospitalized within 30 days. Although various strategies lower hospital readmissions from home, averting readmissions from SNFs has not been studied well.

Investigators evaluated the effect of a new Connected Care team model (versus usual care) on more than 23,000 patients who were discharged from a Cleveland Clinic hospital to 110 different SNFs. More than half of patients were discharged to seven SNFs that were using the Connected Care model — composed of hospital or healthcare system physicians and advanced practice professionals who visited patients four or five times weekly at SNFs …