Table 2.

Major Themes and Illustrative Quotes

Theme	Hospital Provider	SNF Provider
Increasing Patient Complexity	[patients are] “…teetering on the verge of hospitalization all the time.”	“What’s come out of the hospital now was always treated in the hospital years ago, to a large extent. People are coming out quicker. They’re coming out sicker.”
	“…a lot of people don’t like to hear about that…I still think most families, they don’t want to give – people don’t want to give up.”	“They’re sending them here with the assumption, ‘You’re gonna get rehab. In a couple of weeks you’re gonna get stronger and you’re gonna go home.’ That is totally ridiculous.”
Identifying an Optimal Care Setting	“From the perspective of the medical team it is much easier, orders of magnitude easier to get someone to a facility than it is to get them home…. especially when they’re elderly, frail and sick.”	“…we don’t operate the same way as hospitals do. We don’t have so much support. We don’t have so many employees to do those extra tasks. We have one nursing supervisor for the entire house, and it’s [more than 100] beds.”
	“…for me personally, the SNFs that don’t send their patients back to the hospital, the SNFs that are able to get their patients home for me are the better ones. We have some SNFs that you send out a patient to, and they bounce right back, sometimes the next day, sometimes two days.”	“…if you really want to be the place that they’ll send people to, you want your number of readmissions within 30 days to be very low, that you’re able to care for what you take.”
Rising Financial Pressure	“We have to look at the insurances and what the insurance will either first, pay for, or if it’s private insurance, of who are they on par with…. That also can affect patient’s choice, that it narrows down the number of facilities that they would have an option to go to.”	“…if they are a money-making patient, a short-term patient, you don’t want another facility to capture it before you do.”
	“I don’t understand why they’re allowed to refuse people…. We would never ever not take somebody in and care for them, and we, sometimes, just patients are left here for months because no one will take them, and that’s sad.”	“I have a feeling in about 30 days there’s gonna be a backlash. It’s gonna be ‘why did you say that patient could come. This patient just cost us $45,000.’”
		“The hospital gets paid, I believe, according to the diagnosis….the goal is to get this patient out so we get more bang for our buck. Let’s just get this patient out, get them to a different level.”
		“We’re all now scrambling around in a hurry trying to get the patient in and out quick, when how come we’re not focusing on the patient and meeting their needs? I feel like we’re helping the insurance companies. I don’t feel like we’re helping the patients.”
Barriers to Effective Communication	“Some people are very detailed in their written word, but when you have 14 patients and you’re trying to discharge half of them to a facility and you have that many discharge summaries to do, I would say most providers will not spend an hour on every discharge summary making sure that it is very detailed and really relays every aspect of the patient’s hospital stay and their medical needs.”	“It’s almost embarrassing when you have to ask the family what happened in the hospital.”
	“I just don’t have a good understanding of how medical care works at short-term rehab…. Are they seeing a doctor every day? Yeah, that’s a black box for me.” “If we are having difficulty discharging them to the community because we feel like they don’t have the resources to support them, the skilled nursing facility is going to anticipate the same difficulty discharging them from their facility.”