Perspectives of Clinicians at Skilled Nursing Facilities on 30-Day Hospital Readmissions: A Qualitative Study
BACKGROUND: Unplanned 30-day hospital readmissions are an important measure of hospital quality and a focus of national regulations. Skilled nursing facilities (SNFs) play an important role in the readmission process, but few studies have examined the factors that contribute to readmissions from SNFs, leaving hospitalists and other hospital-based clinicians with limited evidence on how to reduce SNF readmissions.
OBJECTIVE: To understand the perspectives of clinicians working at SNFs regarding factors contributing to readmissions.
DESIGN AND PARTICIPANTS: We prospectively identified consecutive readmissions from SNFs to a single tertiary-care hospital. Index admissions and readmissions were to the hospital’s inpatient general medicine service. SNF clinicians who cared for the readmitted patients were identified and interviewed about root causes of the readmissions using a structured interview tool. Transcripts of the interviews were inductively analyzed using grounded theory methodology.
RESULTS: We interviewed 28 clinicians at 15 SNFs. The interviews covered 24 patient readmissions. SNF clinicians described a range of procedural, technological, and cultural contributors to unplanned readmissions. Commonly cited causes of readmission included a lack of coordination between emergency departments and SNFs, poorly defined goals of care at the time of hospital discharge, acute illness at the time of hospital discharge, limited information sharing between a SNF and hospital, and SNF process and cultural factors.
CONCLUSION: SNF clinicians identified a broad range of factors that contribute to readmissions. Addressing these factors may mitigate patients’ risk of readmission from SNFs to acute care hospitals. Journal of Hospital Medicine 2017;12:632-638. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Strengths and limitations
To our knowledge, this is the first interview-based study examining SNF clinicians’ perspectives on unplanned, 30-day hospital readmissions. We gathered information from clinicians with a range of clinical experience, all of whom had cared directly for the patient who had been readmitted. Our data came from clinicians at 15 SNFs of varying sizes and quality ratings, allowing us to identify a broad range of factors contributing to readmissions.
Because this study relied on qualitative methods, it should be viewed as hypothesis-generating rather than hypothesis-confirming. Further research is needed to determine whether variables related to the themes above are causally linked to SNF readmissions. We identified cases for review using convenience sampling of a cohort of readmitted patients at a single tertiary-care hospital, and all participating SNFs were located in Connecticut. These factors may limit the generalizability of our findings. Although the clinicians we interviewed occupied diverse roles within their respective SNFs, our sample did not include direct-care staff without managerial responsibility, such as certified nursing assistants or licensed practical nurses. This prevented our study from identifying themes into which managers would have limited insight, especially those involving cultural and management practices leading to poor communication between them and their staff. Because our study examines cases in which discharge and readmission were to a general medicine service, it may not describe factors relevant to patients discharged from subspecialist or surgical services.
Implications for future QI efforts and research
Several clinicians we interviewed suggested that readmissions might be reduced by dedicating the services of a hospital professional, such as a nurse or case manager, to monitoring the clinical course of medically complex patients after discharge. A dedicated “transition coach” could clarify deficiencies in discharge paperwork, facilitate necessary follow-up appointments, liaise with staff at both the hospital and the SNF, or coordinate acquisition of necessary equipment. Prospective trials have demonstrated that such interventions can decrease readmission rates among hospitalized patients,22,23 but formal studies have not been carried out among cohorts of SNF patients.
Prior efforts to improve SNF-ED information sharing have focused on making sure that ED clinicians have important baseline information about patients transferred from a SNF.24,25 The experiences of SNF clinicians in our study suggest that important information also fails to make its way from ED providers to SNFs and that this failure results in unnecessary readmissions of relatively stable SNF patients. Thus, hospitals may be able to prevent SNF readmissions by creating lines of communication between EDs and SNFs and by ensuring that ED physicians and mid-level providers are familiar with the clinical capabilities of local SNFs.
Future research and QI work should also investigate approaches to care coordination that ensure that complex patients are placed in SNFs with resources adequate to address their comorbidities. Potential interventions might include increased use of SNF “liaisons,” who would evaluate patients in-person prior to approving transfer to a given SNF. As has been previously suggested,26 hospitals might also reduce readmissions by narrowing the pool of facilities to which they transfer patients, thereby building more robust, interconnected relationships with a smaller number of SNFs.
CONCLUSION
SNF clinicians identified areas for improvement at almost every point in the chain of events spanning hospitalization, discharge, and transfer. Among the most frequently cited contributors to readmissions were clinical instability at the time of discharge and omission of clinically important information from discharge documentation. Improved communication between hospitals, ED clinicians, and SNFs, as well as more thoroughly defined goals of care at the time of discharge, were seen as promising ways of decreasing readmissions. Successful interventions for reducing readmissions from SNFs will likely require multifaceted approaches to these problems.
Disclosure: This research was supported by a grant (#P30HS023554-01) from the Agency for Healthcare Research and Quality (AHRQ) and received support from Yale New Haven Hospital and the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (#P30AG021342 NIH/NIA).
