ArticleJoint Commission journal on quality and patient safety2017
Care Transitions Between Hospitals and Skilled Nursing Facilities: Perspectives of Sending and Receiving Providers.
Article in Joint Commission journal on quality and patient safety, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 36 papers, 1 of them a synthesis that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
36 citing papers in PubMed, 1 synthesis or guideline pooled it.
- "Comprehensive Care" Concept in Nursing: Systematic Review.Investigacion y educacion en enfermeria · 2022Pooled it
- Results of a Feasibility Pilot Pragmatic Trial Implementing Palliative Care in Skilled Nursing Facilities.Journal of palliative medicine · 2025Trial
- 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
- Beyond the Hospital Residential Aged Care Home Referral: A Critical Realist Exploration of Residential Aged Care Admission Practices Directly From Hospital.Australasian journal on ageing · 2026Article
- An Updated Mortality and Community Discharge Prognostic Model for Older Adults Admitted to Skilled Nursing Facilities for Post-Acute Care.Journal of the American Medical Directors Association · 2026Article
- Post-Hospital Access to Preferred and High-Quality Skilled Nursing Facilities for Patients With Opioid Use Disorder.Health services research · 2026Article
- Swaying Information About Care: Information-Sharing Challenges in Transitional Care of Older Adults in Japan.Journal of cross-cultural gerontology · 2026Article
- Navigating Postacute Care Options for Patients After Hospital Discharge: A Review.JAMA internal medicine · 2026Review
- Organizational and financial challenges in care transitions: a qualitative study of long-term care systems in Germany, the Netherlands and Poland.BMC geriatrics · 2025Article
- A Multi-Outcome Prognostic Model for Community-Dwelling Older Adults Admitted to Skilled Nursing Facilities for Post-Acute Care.Journal of the American Medical Directors Association · 2025Article
- Hospital and Skilled Nursing Facility Networks: Informal Relationships and Their Role in the Placement of Traditional Medicare Beneficiaries With Serious Mental Illness.Health services research · 2025Article
- 'They Were Talking to Each Other but Not to Me': Examining the Drivers of Patients' Poor Experiences During the Transition From the Hospital to Skilled Nursing Facility.Health expectations : an international journal of public participation in health care and health policy · 2025Article
- Artificial intelligence in transitional care: practice, promise, and pitfalls-a scoping review.Frontiers in digital health · 2025Review
- Consensus and controversies on post-acute care decision making and referral to geriatric rehabilitation: A national survey.International journal of nursing studies advances · 2024Article
- Barriers and facilitators to providing rehabilitation for long-term care residents with dementia: a qualitative study.BMC geriatrics · 2024Article
- Article
- 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
- Information sharing to support care transitions for patients with complex mental health and social needs.Journal of the American Geriatrics Society · 2023Article
- Implementation of a telehealth videoconference to improve hospital-to-skilled nursing care transitions: Preliminary data.Journal of the American Geriatrics Society · 2022Article
Corrections and comments
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Authors and funding
6 authors.
Funding
Abstract
backgroundOne in four Medicare patients hospitalized for acute medical illness is discharged to a skilled nursing facility (SNF); 23% of these patients are readmitted to the hospital within 30 days. The care transition from hospital to SNF is often marked by disruptions in care and poor communication among hospital and SNF providers. A study was conducted to identify the perspectives of sending and receiving providers regarding care transitions between the hospital and the SNF.
methodsHospital (N = 25) and SNF (N = 16) providers participated in qualitative interviews assessing patient transfers and experiences with unplanned hospital readmissions. Data were analyzed by a multidisciplinary coding team using the constant comparison method.
resultsFour main themes emerged: increasing patient complexity, identifying an optimal care setting, rising financial pressure, and barriers to effective communication. The data highlighted hospital and SNF providers' shared concerns about patient-level risk factors and escalating costs of care. The data also identified issues that separate hospital and SNF providers, including different access to resources and information.
conclusionHospital and SNF providers are challenged to meet the needs of complex patients. They are asked to establish comprehensive care plans for patients with significant medical and psychosocial issues while navigating tense relationships between health care institutions and rising financial pressures. The concerns of both hospital and SNF providers must be considered in order to develop practices that can improve the quality, cost, and safety of care transitions.
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Registered trials
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