Original Research

Impact of a Connected Care model on 30-day readmission rates from skilled nursing facilities



About one-fifth of hospitalized Medicare beneficiaries are discharged to skilled nursing facilities (SNFs) for post-acute care. Readmissions are common but interventions to reduce readmissions are scarce.


To assess the impact of a connected care model on 30-day hospital readmission rates among patients discharged to SNFs.


Retrospective cohort.


SNFs that receive referrals from an academic medical center in Cleveland, Ohio.


All patients admitted to Cleveland Clinic main campus between January 1, 2011 and December 31, 2014 and subsequently discharged to 7 intervention SNFs or 103 control SNFs.


Hospital-employed physicians and ad­vanced practice professionals (nurse practitioners and physicianassistants) visited SNF patients 4 to 5 times per week.


During the study period, 13,544 patients were discharged to SNFs within a 25-miles radius of Cleveland Clinic main campus. Of these, 3334 were discharged to 7 intervention SNFs and 10,201 were discharged to 103 usual-care SNFs. During the intervention phase (2013-2014), adjusted 30-day readmission rates declined at the intervention SNFs (28.1% to 21.7%, P < 0.001), while there was a slight increase at control SNFs (27.1 % to 28.5%, P < 0.001). The absolute reductions ranged from 4.6% for patients at low risk for readmission to 9.1% for patients at high risk, and medical patients benefited more than surgical patients.


A program of frequent visits by hospital employed physicians and advanced practice professionals at SNFs can reduce 30-day readmission rates. Journal of Hospital Medicine 2017;12:238-244. © 2017 Society of Hospital Medicine

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