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

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 follow-up care of all discharged patients. The intervention took place from July 2021 to December 2021. Program Evaluation: During the study, 544 patients were discussed in a post-discharge virtual encounter. After the discussions, hospitalists identified clinically significant errors in 124 discharge summaries. A survey of participating hospitalists and SNF medical and nursing leadership indicated the intervention was thought to improve care transitions. Discussion: Our innovation was successful in identifying errors in discharge summaries and was thought to improve the transition of care by participating SNF and hospitalist providers. [ABSTRACT FROM AUTHOR]

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