JUNE 10-14, 2019   •  Las Vegas, NV
Navigating the Full Spectrum of Case Management • Mirage Convention Center

PP305 – Improving Transitions to Skilled Nursing Facilities

Jun 13 2019
10:00 am - 12:00 pm

PP305 – Improving Transitions to Skilled Nursing Facilities

Transitioning to a skilled nursing facility (SNF) is a stressful and often unplanned experience for patients and their families. The decision for SNF placement is often made under time constraints and can result in patients feeling rushed and underprepared for this transition.  Research shows that nursing facility quality was rarely a deciding factor in the decision-making process and patients felt that discharge planners were minimally involved in the selection process.  At Spaulding Rehabilitation Hospital, case managers were interviewed to better understand their current practice related to SNF transitions and their knowledge of quality measures.  Our data shows that there is high variability among case managers with the information presented to patients and their families.  To standardize this process, we provided education to the case management department and developed a written patient educational guide to ensure that patients received thorough and consistent information to prepare for SNF discharge.  Our poster will educate conference attendees on the development of this quality improvement project highlighting levels of care, CMS star rating, the Partners SNF Collaborative, additional online resources, and a list of questions to ask when touring a SNF.   


1. Name two online resources that are helpful for patients and families when researching SNF options

2. Name the three core dimensions that contribute to the CMS 5-star rating system

3. Describe the Partners SNF collaborative