Table 2.
Themes associated with quality initiatives to reduce 30-day SNF-to-hospital readmissions
| References | Positive facilitators | Negative barriers |
|---|---|---|
| Bisiani and Jurgens12 | 1. Identification of at-risk patients can help tailor treatment | 1. Point of entry RN care manager and case. Management assistants do not reduce readmission rates |
| 2. Collaborative case management associated with lower readmissions | 2. Modification of work flows did not reduce readmission rates | |
| 3. Interventions saved $412 per patient | 3. Challenge in finding experienced case managers | |
| 4. Post-discharge telephone call reduces readmission | ||
| 5. Use of a post-discharge advocate nurse | ||
| 6. Senior leadership develop service design and strategy | ||
| 7. Medication reconciliation decreased adverse events, lowers hospital readmissions | ||
| 8. Use of the modified brokerage case management model | ||
| Meehan et al14 | 1. INTERACT | 1. Some leaders did not see compelling reason to participate |
| 2. Conducting root cause analyses of transferred residents | 2. Additional support needed to bring about QI initiatives, not enough time | |
| 3. Providing SNF institutional information to local emergency departments | 3. Not all the QI tools were implemented equally | |
| 4. Leadership is critical to success of QI initiatives | 4. Staff lacked technologic capabilities to use hospital tracking tools | |
| 5. SBAR form and progress note | ||
| Wood18 | 1. Use of the Shewhart cycle of plan-do-check-act and state action on avoidable rehospitalizations | 1. Insufficient education among SNF staff in cardiac care |
| 2. Knowledge gap in cardiac care identified, education provided in assessment, care, and interventions | 2. Patients being readmitted for preventable or manageable conditions | |
| 3. Nurse practitioner involvement | 3. Only 75% of staff returned educational surveys and tests | |
| Lu et al11 | 1. Including pharmacists on multidisciplinary team helps reduce readmission rates | 1. One study did not show significant reduction following medication reconciliation, medication errors are common in SNFs |
| 2. Use of a standard discharge order reconciliation process and not discharging after 2 pm | 2. Two extreme severity of illness groups did not have statistical reductions in readmission rates. The illness is more important than medication reconciliation | |
| 3. Medication reconciliation and 2–4 day follow up reduces hospital readmissions | ||
| 4. Improving electronic workflow reduced medication errors | ||
| 5. Limited financial resources required for meaningful results | ||
| 6. Executive leaders supported evidence-based changes | ||
| 7. Pharmacist involvement in medication reconciliation reduced discrepancies | ||
| Sandvik et al16 | 1. Geriatric community forum used to promote multidisciplinary collaboration | 1. Challenges with implementation and staff engagement. Little coordination between facilities, physicians, and hospitals |
| 2. Nurse-to-nurse telephone report using SBAR | 2. Low readmission rate could reflect poor-quality choices | |
| 3. Using a single set of forms with checklists during patient transfer | 3. Transfer forms not always completed by sending physicians | |
| 4. Medication list with diagnosis for each medication and comments helps to reduce errors | 4. Personnel turn over causes loss of institutional knowledge and continuity of QI project | |
| 5. Advanced directive form can reduce undesired hospitalizations | 5. Hospitalists with less nursing home experience overall began completing transfers | |
| 6. Universal documentation with prompts, safety reminders, and checklists | 6. Improper transfer of patient data, improper documentation, missing orders had been prior issue | |
| Maly et al20 | 1. Collaborative partner prioritization tool | 1. Aligning hospitals and SNFs requires like-minded leaders that are willing to invest time and effort |
| 2. Use of SBAR communication tool | 2. QI project needs time to grow in order to track and report findings | |
| 3. Hospital/SNF collaboration involving patient information and clinical educational resources | ||
| 4. Sharing of protocols for care of patients with congestive heart failure, post-myocardial infarction, and pneumonia | ||
| 5. Telehealth neurologic consults | ||
| 6. Physician form for aligning goals and sharing interest | ||
| Ouslander et al15 | 1. QI intervention using INTERACT II | 1. Challenges with implementation were found |
| 2. Leadership participated with in-person and telephone meetings | 2. SNF self-reporting of hospitalizations might not be accurate. Seasonal variation in hospitalizations | |
| 3. Improved advanced care planning and consideration of palliative care | 3. Four SNFs dropped out do to loss of champion or administrator | |
| 4. Staff attended 4–6 hours of orientation | 4. Cost of QI intervention is ~$15,400 per year. Less-costly initiatives are needed | |
| 5. Managing conditions proactively to prevent them from becoming more severe | 5. Leaders have completing goals including census goals, preparation for surveys, and other QI initiatives | |
| 6. Printed forms for SNF administrators to review cause of acute transfers | 6. Physicians and mid-level providers were not actively engaged in using QI tools | |
| 7. Pocket card and half-page report forms and progress note templates | ||
| 8. Envelopes for transfer documents with checklist on outside | ||
| 9. Longer serving SNF administrators and lower RN turnover | ||
| 10. Use of a staff member as a QI champion | ||
| Ouslander et al19 | 1. Guidelines developed to reduce readmissions for common causes of rehospitalization | 1. Staffing challenges are biggest barrier |
| 2. Data support the need to monitor SNF quality to reduce readmissions | 2. Medicare fee-for-service system and declining reimbursement do not incentivize continued care of sicker patients | |
| 3. Managed care programs that use physicians, nurse practitioners, and physician assistants | ||
| 4. Implementation of just some of the guidelines showed positive outcomes | ||
| Berkowitz et al17 | 1. Physician admission procedures were standardized | 1. No criteria for physician judgment on the appropriateness of patient transfers to the hospital |
| 2. Patients with 3+ prior hospital admissions in past 6 months got palliative care consult. More likely to die outside of acute care setting according to wishes. Use of hospice teams to give palliative consults | 2. Intervention would need to be adapted for facilities without onsite medical staff | |
| 3. Bimonthly multidisciplinary root cause analysis conferences for patients fitting within readmission parameters to review whether or not readmissions could have been prevented | 3. SNFs are not always reimbursed for the extra care high acuity patients require | |
| 4. Medication reconciliation template | ||
| 5. Use of a nurse practitioner and on site medical staff can assess acute medical conditions quickly | ||
| 6. A lessons learned email was sent out to direct care staff | ||
| 7. The shaping long-term care in America project data can be used to compare QI success | ||
| Ouslander et al13 | 1. QI using the INTERACT | 1. Participation varied and no SNF implemented all the QI tools |
| 2. Use of physicians, nurse practitioners, or physician assistants | 2. The SBAR communication tool and “Stop and Watch” tool for CNAs were viewed as too much paperwork | |
| 3. The leadership panel was aware of QI purpose and may have been biased in reporting. Not a controlled study | ||
| 4. Physicians and mid-level providers were not engaged in QI despite multiple communications |
Abbreviations: CNA, certified nursing assistant; INTERACT, intervention to reduce acute care transfers; QI, quality improvement; RN, registered nurse; SBAR, situation background assessment recommendation; SNFs, skilled nursing facilities.