Table 1.

Studies selected for review and a summary of design, methods, and results

Author/date/location	Aim	Sample/settings	Methods	Assessment tool	Key findings
Bisiani and Jurgens12/August 2015/NY, USA	Evaluate and compare two care management models on 30-day hospital readmission rates	13,000 medical records prior and 978 medical records after intervention from a Community Hospital	Retrospective, quasi-experimental, interrupted time series	Medical record data	Patient characteristics, addition of positions, and modification of workflows did not impact hospital readmission rates from SNFs
Meehan et al14/August 2015/CT, USA	Evaluate the impact of INTERACT QIO-training on decreasing 30-day hospital readmissions from SNFs	Staff from 5 SNFs in surrounding community with ≥40 beds and ≥10% 30-day medicare beneficiary readmission rates	Retrospective, quasi-experimental, mixed methods	Hospitalization tracking tool data; staff-reported contact log; staff surveys	Mixed clinical results
Wood18/2014/MA, USA	Define causes of hospital readmission of cardiac surgery patients from a SNF and test impact of education on 30-day readmission rate	All cardiac surgery patients discharged from the Medical Center to a SNF and the 20 nurses at that SNF	Retrospective, quasi-experimental, mixed methods	Medical record data, initial nursing survey; pre-test and post-intervention test	Evidence of a knowledge deficit and an educational need among the SNF staff nurses caring for cardiac surgery patients
Lu et al11/May 2013/MN, USA	Determine if QI initiative focused on discharge orders and medication reconciliation at a hospital can decrease 30-day readmissions from patients discharged to SNFs	A designated intervention group of 87 patients and a control group of 1,893 patients discharged to SNFs from a teaching hospital	Retrospective, quasi-experimental, interrupted time series	Medical record data	Standardized discharge order reconciliation with pharmacist involvement in medication reconciliation led to decreased readmission rates for patients discharged from a hospital to SNFs
Sandvik et al16/May 2013/SD, USA	Evaluate the effectiveness of universal patient transfer protocols and a collaborative community forum on reducing 30-day readmission rates from hospitals to SNFs	705 Medicare patients discharged from the hospital to SNFs	Retrospective, quasi-experimental, cross-sectional	Medicare claims data; surveys	Standardized transfer forms and processes developed between hospitals and SNFs help to reduce 30-day readmission rates
Maly et al20/2012/PA, USA	Determine if hospital-SNF collaboration using physician partnerships, education, telemedicine, and EMR sharing can reduce 30-day readmission	A community hospital system and 29 surrounding SNFs	Retrospective, quasi-experimental, cross-sectional	Medicare claims data	SNFs with a medical director affiliated with the referring hospital had lower all-cause hospital readmission rates
Ouslander et al15/March 2011/USA	Determine if the QI program INTERACT II could reduce hospital readmission rates from SNFs	25 participating SNFs and 11 comparison SNFs located in Florida, Massachusetts, and New York	Retrospective, quasi-experimental, interrupted time series	Surveys: medical record data; SNF reported data	SNFs with the highest engagement in the QI program had the greatest reduction in hospital readmission rates
Ouslander et al19/March 2011/FL, USA	Determine the frequency and diagnosis associated with 7- and 30-day hospital readmissions from SNFs	3,254 Medicare patients 75 and older who were discharged from a 350-bed nonteaching community hospital to a SNF	Retrospective, quasi-experimental, cross-sectional	Medical record data	CHF, renal failure, UTI, pneumonia, and COPD were the most common diagnosis associated with hospital readmissions from SNFs
Berkowitz et al17/2011/MA, USA	Evaluate an intervention to improved discharged disposition from a skilled nursing recuperative services unit of a hospital	862 patients discharged before the intervention and 863 during the intervention from a 50-bed SNU associated with a hospital	Prospective, quasi-experimental interrupted time series	Administrative discharge disposition data; MDS assessment data	Standardized admission procedures, palliative care consultations, multidisciplinary conferences within a skilled nursing facility led to a decline in readmissions to acute care
Ouslander et al13/2009/GA, USA	Test tools and strategies designed to assist SNFs in reducing potentially avoidable hospitalizations over 6 months	Ten pre-intervention hospitalizations were compared to 65 post-intervention hospitalizations from 3 different SNFs	Prospective, quasi-experimental interrupted time series	Direct observation; survey; MDS data; Medicare data	Despite only partial implementation, the quality improvement initiative was associated with a 50% reduction in the overall rate of potentially avoidable hospitalizations

Abbreviations: CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; EMR, electronic medical record; INTERACT, intervention to reduce acute care transfers; MDS, minimum data set; QIO, quality improvement organization; SNFs, skilled nursing facilities; SNU, skilled nursing unit; UTI, urinary tract infection.