Proactive Care in SNFs: Preventing Unnecessary Hospitalizations

-Written by Shraddha Majcher

“Well, hello, Mr. Rogers!” Nurse Rita said warmly, upon entering her patient’s hospital room. “It is good to see you again but not under these circumstances.”

Mr. Rogers nodded wearily and tried to speak through his oxygen mask. “It seems that I somehow developed pneumonia while I was in rehab. I am back in the hospital for you to have to fix me up again.”

Nurse Rita replied, “ I read in your chart that you were walking with a cane and planning to be released to go home until this happened. We will get you back on your feet in no time.” However, she was very worried that this episode may just set Mr. Rogers too far back from making a full recovery.

Hospital readmissions from skilled nursing facilities (SNFs) or within 30 days of discharge to home remain a significant challenge, despite the importance of SNF short-term rehab and its proven outcomes in value-based care models. By implementing structured interventions, SNFs and hospitals can collaborate to improve patient transitions and reduce avoidable rehospitalizations.

Key Causes of Hospital Readmissions from SNFs :

Hospital readmissions often stem from common conditions such as:

Cardiac conditions, such as heart failure, status post CABG surgery, and acute myocardial infarctions
Respiratory complications, including pneumonia, respiratory failure, aspiration pneumonitis, and COPD exacerbations
Septicemia, Urinary tract infections (UTIs), and other infections
Elective Total Hip and Knee Arthroplasty surgeries
Acute/Unspecified Renal Failure
Gastrointestinal hemorrhage and intestinal infections
Falls
Unresolved Hospital-acquired conditions (HACs): The 14 categories from CMS are: Foreign object retained after surgery, Air embolism, Blood incompatibility, Stage III and IV pressure ulcers, Falls and trauma, Manifestations of poor glycemic control, Catheter-associated UTI, Vascular catheter-associated infection, Surgical site infection, mediastinitis, following coronary artery bypass graft, Surgical site infection following bariatric surgery for obesity, Surgical site infection following certain orthopedic procedures, Surgical site infection following cardiac implantable electronic device, Deep vein thrombosis/pulmonary embolism following certain orthopedic procedures, Iatrogenic pneumothorax with venous catheterization)

To reduce these risks, structured and coordinated care strategies can be implemented to ensure early detection and intervention.

INTERACT: Preventing Avoidable Hospital Transfers

The INTERACT program is a widely used quality improvement initiative that focuses on early recognition and management of changes in a patient’s condition to prevent unnecessary hospitalizations.

Key Components of INTERACT:
- Standardized communication format to ensure clear, concise patient updates to physicians.
- Example: Reporting signs of productive or non-productive cough or abnormal lung sounds for pneumonia in a patient allows for timely antibiotic administration in the SNF instead of a hospital admission.
Decision Support Tools & Care Pathways
- Guides clinical teams in managing conditions like UTIs, pneumonia, and heart failure within the SNF.
- Example: A structured pathway for CHF exacerbation helps adjust diuretics and manage fluid intake in-house rather than transferring the patient to the hospital.
Advance Care Planning Tools
- Ensures patients’ end-of-life preferences are considered, preventing unwanted hospitalizations.
- Example: The family of a patient with advanced dementia and recurrent infections may opt for comfort-focused care at the SNF.

Project RED: Enhancing Safe Transitions from SNF to Home

Project RED is a structured discharge planning model that enhances patient education, follow-up care, and medication reconciliation to prevent hospital readmissions.

Key Components of Project RED:

Comprehensive Discharge Education
- Patients and caregivers receive personalized instructions on medication use, red flags, and self-care strategies.
- Example: A Chronic Heart Failure patient is taught to monitor fluctuations in weight and sodium intake to prevent readmission.
Medication Reconciliation
- Ensures clarity on medications post-discharge, preventing polypharmacy and adverse reactions.
- Example: A patient discharged with a new blood thinner medication receives clear dosing instructions to avoid complications.
Follow-Up Appointments Scheduled Before Discharge
- Ensures timely follow-up with primary care and specialists.
- Example: A myocardial infarction patient is scheduled for a cardiologist visit within a week of discharge.
Teach-Back Method
- Patients must demonstrate an understanding of their care plan before discharge.
- Example: A patient recovering from knee surgery repeats medication instructions to confirm comprehension.
Follow-Up Phone Calls Within 48 Hours
- A nurse checks on patient stability and addresses concerns post-discharge.
- Example: The daughter of a post-stroke patient confirms adherence to safety with transfers and use of hemi-walker with a gait belt every time the patient gets up.

Optimizing Medication Management to Reduce Readmissions

Thorough medication reconciliation upon SNF admission
Reassess medications held during hospitalization, such as diuretics, to determine necessity
Refer to specialists if status management is unclear
Deprescribe high-risk geriatric medications when unnecessary (e.g., antipsychotics started for hospital-induced delirium)
Minimize the use of urinary catheters, PICC lines, and other devices that may increase infection risk

The Importance of a Targeted SNF Network for Readmission Reduction

A study in the Journal in Nursing Home Quality in January of 2021 concluded that a successful strategy was for hospitals to identify SNFs where a critical volume of patients are transferred for enhanced care coordination. Instead of physicians following their patients across multiple SNFs, studies show that integrated hospital systems can successfully establish an in-house medical director presence for selected key SNFs for better care continuity.

Why it works:

Embedding geriatricians as medical directors in SNFs to provide ongoing staff education and after-hours support.
Increased efficiency: Instead of a physician seeing only a handful of patients across multiple SNFs, they become a consistent presence at a few select facilities.
Stronger staff relationships: A dedicated medical director in an SNF fosters better communication, shared goals, and educational opportunities.
Improved information exchange: Holding quarterly SNF meetings and case reviews enhances collaboration and reduces care fragmentation.
More effective readmission prevention: A consistent provider at the SNF can proactively intervene, avoiding unnecessary hospital transfers.

Building Effective Systems of Care Through Collaboration

Based on relational coordination theory, effective transitions of care require shared goals, mutual respect, and seamless communication across hospital and SNF teams.

Why it works:

Quarterly educational meetings between hospitals and SNFs encourage alignment on best practices.
Case reviews between SNFs and hospital readmission committees can analyze trends and improve care processes.
Biweekly readmission committee meetings allow SNF staff to voice concerns and collaborate on solutions.

Targeting High-Risk Conditions

To reduce hospital readmissions, skilled nursing facilities (SNFs) highly benefit from implementing structured systems for monitoring residents with fluctuating clinical status. Research (PLOS 2022 Jan 20) indicates that over 25% of residents transferred to hospitals lacked documented vital signs, and over 80% had not been seen by a medical provider within 72 hours before transfer. This gap in early detection is particularly concerning for conditions such as pneumonia and sepsis, which require immediate medical intervention.

A proactive strategy includes developing standard practices for routine monitoring of vital signs, symptoms, and early warning indicators of deterioration. Establishing clear protocols for reporting abnormal findings to medical providers can help facilitate timely intervention. In cases where an in-person examination is not immediately feasible, telehealth consultations may provide an effective alternative for rapid assessment and decision-making.

Research indicates that five of the six HRRP-targeted conditions (Acute MI, COPD, Pneumonia, Heart Failure, CABG surgery) often lead to readmissions due to:

Organ dysfunction and impaired homeostasis
Medication adjustments made during hospital stays that weren’t reconvened at an appropriate time
Lack of early detection of abnormal vitals
Inability to report abnormal findings to a medical provider quickly

Personalized Clinical Interventions

To reduce readmissions, interventions should be tailored to patient comorbidities.

Examples include:

Heart Failure: Monitoring fluid balance, reassessing diuretics, and scheduling cardiology follow-ups.
COPD: Ensuring inhaler technique proficiency, optimizing pulmonary rehabilitation, and scheduling early follow-ups with pulmonology.
Diabetes: Coordinating blood sugar monitoring, reviewing insulin regimens, and addressing dietary concerns.
Post-Surgical Patients: Implementing wound care protocols, ensuring pain management adherence, and preventing infections.
Cognitive Impairment: Providing structured caregiver education, medication management, and behavioral intervention support.

Advanced Care Planning in SNFs:

Routine discussions about short- and long-term prognosis
Aligning care decisions with patient preferences
Reducing unnecessary hospitalizations through informed decision-making
SNFs could monitor fluid balance and reassess medication regimens upon admission.

Conclusion

Reducing hospital readmissions from SNFs requires a multi-faceted approach, and there are tools and research-backed interventions to help! To summarize a few mentioned here:

INTERACT for early intervention and clinical decision support
Project RED for structured discharge planning and follow-up care
Medication reconciliation and polypharmacy reduction
Hospitals Targeting SNFs with high patient volume and implementing onsite physicians/medical directors for better provider continuity
Enhanced structured and scheduled communication and coordination between SNFs and hospitals
Tailoring interventions based on high-risk conditions and comorbidities

By implementing strategies like these, SNFs and hospitals can significantly improve patient outcomes, reduce rehospitalizations, and create a more efficient, patient-centered healthcare system.

About Author:

Shraddha (like Prada) Majcher brings over 20 years of dedicated experience as a physical therapist and industry writer blending clinical insight with a knack for spotlighting progressive patient-centered care, provider empowerment, and operational excellence.

In her latest piece for Innova Health, she explores proactive strategies for skilled nursing facilities (SNFs) to prevent unnecessary hospital readmissions—highlighting structured interventions, early detection, and stronger care transitions that put patients and providers on the same page.