ArticleJournal of the American Geriatrics Society2017
Potentially Avoidable Readmissions of Patients Discharged to Post-Acute Care: Perspectives of Hospital and Skilled Nursing Facility Staff.
Article in Journal of the American Geriatrics Society, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 29 papers.
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Who cites it
29 citing papers in PubMed.
- Improving Hospital-to-Skilled Nursing Facility Transitions: Resident-Led Implementation and Evaluation of an EHR-Embedded Discharge Checklist.Joint Commission journal on quality and patient safety · 2026Article
- Collaborative Working to Address Inappropriate ED Attendances by Nursing Home Residents.BMJ open quality · 2025Article
- Access to preferred skilled nursing facilities: Transitional care pathways for patients with Alzheimer's disease and related dementias.Health services research · 2024Article
- Hospitalists Improving Transitions of Care Through Virtual Collaborative Rounding with Skilled Nursing Facilities-the HiToC SNF Study.Journal of general internal medicine · 2023Article
- Prediction of rehospitalization and mortality risks for skilled nursing facilities using a dimension reduction approach.BMC geriatrics · 2023Article
- Care patterns and predictors of community residence among older patients after hospital discharge for traumatic brain injury.Journal of the American Geriatrics Society · 2023Article
- Readmission of Patients to Acute Psychiatric Hospitals: Influential Factors and Interventions to Reduce Psychiatric Readmission Rates.Healthcare (Basel, Switzerland) · 2022Review
- Outcomes of complex discharge planning in older adults with complex needs: a scoping review.The Journal of international medical research · 2022Article
- Implementation of a telehealth videoconference to improve hospital-to-skilled nursing care transitions: Preliminary data.Journal of the American Geriatrics Society · 2022Article
- Video-telehealth to support clinical assessment and management of acutely unwell older people in Residential Aged Care: a pre-post intervention study.BMC geriatrics · 2022Article
- Gaps in Hospital and Skilled Nursing Facility Responsibilities During Transitions of Care: a Comparison of Hospital and SNF Clinicians' Perspectives.Journal of general internal medicine · 2021Article
- How Context Influences Hospital Readmissions from Skilled Nursing Facilities: A Rapid Ethnographic Study.Journal of the American Medical Directors Association · 2021Article
- Diverse perspectives on hospitalisation events among people with dementia: protocol for a multisite qualitative study.BMJ open · 2021Article
- Information Sharing Practices Between US Hospitals and Skilled Nursing Facilities to Support Care Transitions.JAMA network open · 2021Article
- Article
- Patient Factors Linked with Return Acute Healthcare Use in Older Adults by Discharge Disposition.Journal of the American Geriatrics Society · 2020Article
- Variability in Transitional Care Outcomes Across Hospitals Discharging Veterans to Skilled Nursing Facilities.Medical care · 2020Observational
- Associations of Skilled Nursing Facility Quality Ratings With 30-Day Rehospitalizations and Emergency Department Visits.The annals of long-term care : the official journal of the American Medical Directors Association · 2020Article
- Perspectives of general practitioners and nursing staff on acute hospital transfers of nursing home residents in Germany: results of two cross-sectional studies.BMC family practice · 2020Article
- Transitional Care Outcomes in Veterans Receiving Post-Acute Care in a Skilled Nursing Facility.Journal of the American Geriatrics Society · 2019Observational
Corrections and comments
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Authors and funding
13 authors.
Funding
Abstract
backgroundHospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF perspectives.
objectivesTo determine the percentage of readmissions from post-acute care that are considered potentially avoidable from hospital and SNF perspectives.
designProspective cohort study.
settingOne academic medical center and 23 SNFs.
participantsWe included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days. MEASUREMENTS: Hospital-based physicians and SNF-based staff performed structured root-cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions.
resultsThe 30-day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively.
conclusionA substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.
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