Skilled nursing facilities (SNFs) play a crucial role in the hospital readmission process.Approximately 1 in 4 Medicare beneficiaries discharged from an acute care hospital is admitted to a SNF instead of returning directly home. Of these patients, 1 in 4 will be readmitted within 30 days,1 a rate significantly higher than the readmission rate of the inpatient population as a whole.2 The 2014 Protecting Access to Medicare Act created a value-based purchasing program that will use quality measures to steer funds to, or away from, individual SNFs. When the program takes effect in 2018, the Centers for Medicare & Medicaid Services will use SNFs’ 30-day all-cause readmission rate to determine which SNFs receive payments and which receive penalties.3 The Affordable Care Act, passed in 2010, has also established penalties for hospitals with higher than expected readmission rates for Medicare patients.4
Despite this intensifying regulatory focus, relatively little is known about the factors that drive readmissions from SNFs. A prospective review of data from SNFs in 4 states has shown that SNFs staffed by nurse practitioners or physician assistants and those equipped to provide intravenous therapy were less likely to transfer patients to the hospital for ambulatory care-sensitive diagnoses.5 Qualitative studies have provided useful insight into the causes of SNF-to-hospital transfers but have not focused on 30-day readmissions.6,7 A single survey-based study has examined the causes of SNF-to-hospital readmissions.8 However, survey-based methodologies have limited ability to capture the complex perspectives of SNF clinicians, who play a critical role in determining which SNF patients require evaluation or treatment in an acute care setting.
To address this gap in knowledge about factors contributing to SNF readmissions, we conducted a qualitative study examining SNF clinicians’ perspectives on patients readmitted to the hospital within 30 days of discharge. We used a structured interview tool to explore the root causes of readmission with frontline SNF staff, with the goal of using this knowledge to inform future hospital quality improvement (QI) efforts.
Hospital data-tracking software (Allscripts) was used to identify patients who experienced a 30-day, unplanned readmission from SNFs to an academic medical center. We restricted our search to patients whose index admission and readmission were to the medical center’s inpatient general medicine service. A study team member (BWC) monitored the dataset on a weekly basis and contacted SNF clinicians by e-mail and telephone to arrange interviews at times of mutual convenience. To mitigate against recall bias, interviews were conducted within 30 days of the readmission in question. A total of 32 cases were identified. No SNF clinicians refused a request for interview. For 8 of these cases, it was not possible to find a time of mutual convenience within the specified 30-day window. The remaining 24 cases involved patients from 15 SNFs across Connecticut. Interviews were conducted from August 2015 to November 2015.
The project was reviewed by our institution’s Human Investigation Committee and was exempted from Institutional Review Board review.
Interviews were conducted on-site at SNFs with groups of 1 to 4 SNF clinicians and administrators. SNF participants were informed of interviewer credentials and the study’s QI goals prior to participation. Participation was voluntary and did not affect the clinician’s relationship with the hospital or the SNF. Participants were not paid.
Interventions to Reduce Acute Care Transfers (INTERACT) is a QI program that includes training for clinicians, communication tools, and advance care planning tools.9 INTERACT is currently used in 138 Connecticut SNFs as part of a statewide QI effort funded by the Connecticut State Department of Public Health. In prospective QI studies,10,11 implementation of INTERACT has been associated with decreased transfers from SNFs to acute care hospitals. The INTERACT Quality Improvement Tool, one part of the INTERACT bundle of interventions, is a 26-item questionnaire used to identify root causes of transfers from SNFs to acute care hospitals. It includes both checklists and open-ended questions about patient factors, SNF procedures, and SNF clinical decision-making.
We used the INTERACT QI Tool12 to conduct structured interviews with nurses and administrators at SNFs. Interviewers used a hard copy of the tool to maintain field notes, and all parts of the questionnaire were completed in each interview. Although the questionnaire elicits baseline demographic and medical information, such as the patient’s age and vital signs prior to readmission, the majority of each interview was dedicated to discussion of the open-ended questions in Table 1. Upon completion of the INTERACT QI Tool, the interviewer asked 2 open-ended questions about reducing readmissions and 4 closed-ended questions regarding SNF admission procedures. (Table 1) The supplemental questions were added after preliminary interviews with SNF clinicians revealed concerns about the SNF referral process and about communication between the hospital, emergency department (ED) and SNFs—issues not included in the INTERACT questionnaire. Interviewers used phatic communication, probing questions, and follow-up questions to elicit detailed information from participants, and participant responses were not limited to topics in the questionnaire and the list of supplemental questions.
Interviews were conducted by a hospital clinical integration coordinator, social worker, and a physician (KB, MCB, BWC). All interviewers received formal training in qualitative research methods prior to the study.
All interviews were audio recorded, with permission from the participants, and were professionally transcribed. Field notes were maintained to ensure accuracy of INTERACT QI Tool data. Participant interviews covered no more than two cases per session and lasted from 18 to 71 minutes (mean duration, 38 minutes).
Analysis of transcripts was inductive and informed by grounded theory methodology, in which data is reviewed for repeating ideas, which are then analyzed and grouped to develop a theoretical understanding of the phenomenon under investigation.13,14
A preliminary codebook was developed using transcripts of the first 11 interviews. All statements relevant to the readmission process were extracted from the raw interview transcript and collected into a single list. This list was then reviewed for statements sharing a particular idea or concern. Such statements were grouped together under the heading of a repeating idea, and each repeating idea was assigned a code. Using this codebook, each transcript was independently reviewed and coded by three study team members with formal training in inductive qualitative analysis (KB, KTM, BWC). Reviewers assigned codes to sections of relevant text. Discrepancies in code assignment were discussed among the 3 analysts until consensus was reached. Using the method of constant comparison described in grounded theory,the codebook was updated continuously as the process of coding transcripts proceeded.12 Changes to the codebook were discussed among the coding team until consensus was achieved. The process of data acquisition and coding continued until theoretical saturation was reached. Themes relating to underlying factors associated with readmissions were then identified based on shared properties among repeating ideas. ATLAS.ti (Scientific Software, Berlin, Germany, Version 7) was used to facilitate data organization and retrieval.
The SNFs in our study included 12 for-profit and 3 non-profit facilities. The number of licensed beds in each facility ranged from 73 to 360, with a mean of 148 beds. The SNFs had CMS Nursing Home Compare ratings ranging from 1 star, the lowest possible rating, to 5 stars, the highest possible,15 with a mean rating of 2.9 stars. Our analysis did not reveal differences in perceived contributions to readmissions from large vs. small or highly rated vs poorly rated SNFs.
The patients in our analysis represented a highly comorbid and medically complex population (Table 3). Many had barriers to communication with clinical staff, including non–English-speaking status and underlying dementia.
Five main themes emerged from our analysis: (1) lack of coordination between EDs and SNFs; (2) incompletely addressed goals of care; (3) mismatch between patient clinical needs and SNF capabilities; (4) important clinical information not effectively communicated by hospital; and (5) challenges in SNF processes and culture.
Emergent transitions: Lack of coordination between ED and SNF
SNF clinicians frequently encountered situations in which a relatively stable patient was readmitted to the hospital after being transferred to the ED, despite the fact that SNF clinicians believed the patient should have returned to the SNF once a specific test was performed or service rendered at the ED. Commonly cited clinical scenarios that resulted in such readmissions included placement of urinary catheters and evaluation for cystitis. An assistant director of nursing reported that “the ER doesn’t want to hear my side of the story,” making it difficult for her to provide information that would prevent such readmissions. Other SNF clinicians reported similar difficulties in communicating with ED clinicians.
Code status: Incompletely addressed goals of care
The SNF clinicians in our study described cases in which patients with end-stage lung disease and disseminated cancer were readmitted to the hospital, despite SNF efforts to prevent readmission and provide palliative care within the SNF. For example, a SNF advanced practice nurse described a case in which a patient with widely metastatic cancer requested readmission to the hospital for treatment of deep vein thrombosis, despite longstanding recommendations from SNF staff that the patient forego hospitalization and enroll in hospice care. After discussion of code status and goals of care with hospital clinicians, the patient chose to enroll in hospice care and not to continue anticoagulation. SNF clinicians often perceived that, in the words of one administrator, “the palliative talks in the hospital outweigh our talks by a lot.” Numerous SNF clinicians believed that in-depth clarification of goals of care prior to discharge could prevent some readmissions.
Wrong patient, wrong place: Mismatch between clinical needs and SNF capabilities
One director of nursing stated that “[when] you read a referral, there’s a huge difference sometimes between what you read and what you see.” SNF clinicians reported that this discrepancy between clinical report and clinical reality often leads to patients being placed in SNFs that are unequipped to care for them. Many patients were perceived as being too ill for discharge from the acute-care setting in the first place. A nurse manager described this as a pattern of “pushing patients out of the hospital.” However, mismatches in clinical disposition were also seen as contributing to readmissions for medically stable patients, such as those with dementia, for whom SNFs frequently lack adequate staffing and physical safeguards.
Missing links: Important clinical information not effectively communicated by hospital
SNF clinicians described numerous challenges in formulating plans of care based on hospital discharge documentation. Discrepancies between discharge summaries and patient instructions were perceived as common and potential causes of readmissions. For patients discharged from the academic medical center in this study, medication instructions are included in both the discharge summary sent to the SNF and in a patient instruction packet. Several SNF clinicians said that it was common for a course of antibiotics to be listed on the discharge summary but not the patient instruction packet, or vice versa. SNF clinicians, who usually lack access to the hospital’s electronic medical record, have limited means for determining the correct document. Other important clinical data points, such as intermittent intravenous (IV) furosemide dosing and suppressive antibiotic regimens, were omitted from discharge paperwork altogether. SNF clinicians had difficulty reaching hospital clinicians who could clarify these clinical questions. “Good luck finding the person that took care of [the patient] three days before,” said one director of nursing.
Change starts at home: Challenges in SNF processes and culture
Many clinicians in our study reported that their facilities had recently added clinical capabilities in an effort to care for patients with complex medical problems. For example, to prevent transfers of patients with decompensated heart failure, several facilities in our study had recently obtained certification to give IV diuretics. However, as one director of nursing stated, these efforts require “buy-in” from doctors to decrease readmissions. That buy-in has not always been forthcoming. SNF clinicians also reported difficulty convincing patients and families that their facilities are capable of providing care that, in the past, might only have been available in acute-care settings.
These themes, along with associated sub-themes and representative quotations, are shown above (Table 4).
Our study suggests that the interaction between EDs and SNFs is an important and understudied domain in the spectrum of events leading to readmission. Prior studies have documented inadequacies in patient information provided by SNFs to EDs.16,17 Efforts to improve SNF-to-ED information sharing have focused on making sure that ED clinicians have important baseline information about patients transferred from a SNF.18,19 However, many of the clinicians in our study reported taking proactive steps to communicate with ED clinicians. These efforts encountered logistical and cultural barriers, with information that might have prevented readmission failing to reach ED providers. Many of the SNF clinicians in our study perceived this failure as a common cause of readmission, especially for relatively stable SNF patients.
Previous studies have pointed to a role for goals of care discussions in reducing hospital readmissions.20 Our data underscore an important qualification to these findings: Location matters. The SNF clinicians in our study reported frequent and detailed goals of care discussions with their patients. However, they also reported that goals of care discussions held in the subacute setting carried less weight with patients and families than discussions held in the hospital. SNF clinicians described a number of cases in which patients were willing to adjust code status or goals of care only after being readmitted to the hospital.
Our study also points to the implications of existing research showing that patients are discharged from acute care hospitals “quicker and sicker” than they had been prior to the 1983 adoption of Medicare’s prospective payment system.21 Specifically, the SNF clinicians we interviewed perceived a strong link between patient acuity at the time of transfer and SNFs’ persistently high readmission rates. As SNFs have worked to expand their clinical capabilities, they struggle to win buy-in from physicians and families, many of whom view SNFs as incapable of managing acute illness. Many SNF clinicians also pointed to deficiencies in their own referral and admission processes as a recurring cause of readmissions. For example, several patients in our analysis suffered from dementia. Although these patients were stable enough to leave the acute care setting, the SNF clinicians responsible for their readmissions felt that their SNFs were not well-equipped to care for patients with dementia and that the patients should instead have been transferred to facilities with more robust resources for dementia care.
Finally, our findings highlight a fundamental tension between hospitals and SNFs: Which facility ought to shoulder the responsibility and cost for services that may prevent a readmission—the hospital or the SNF? For example, does responsibility for coordinating subspecialist evaluation of a patient’s chronic condition fall to the hospital or to the SNF? If such an evaluation is undertaken during a hospitalization, it prolongs the patient’s hospital stay and happens at the hospital’s expense. If the patient is discharged to a SNF and sees the subspecialist in clinic, then the SNF must pay for transportation to and from the clinic appointment. SNF clinicians expressed near unanimity that fragmented models of care and high barriers to communication made it difficult to design solutions to these dilemmas.
Strengths and limitations
To our knowledge, this is the first interview-based study examining SNF clinicians’ perspectives on unplanned, 30-day hospital readmissions. We gathered information from clinicians with a range of clinical experience, all of whom had cared directly for the patient who had been readmitted. Our data came from clinicians at 15 SNFs of varying sizes and quality ratings, allowing us to identify a broad range of factors contributing to readmissions.
Because this study relied on qualitative methods, it should be viewed as hypothesis-generating rather than hypothesis-confirming. Further research is needed to determine whether variables related to the themes above are causally linked to SNF readmissions. We identified cases for review using convenience sampling of a cohort of readmitted patients at a single tertiary-care hospital, and all participating SNFs were located in Connecticut. These factors may limit the generalizability of our findings. Although the clinicians we interviewed occupied diverse roles within their respective SNFs, our sample did not include direct-care staff without managerial responsibility, such as certified nursing assistants or licensed practical nurses. This prevented our study from identifying themes into which managers would have limited insight, especially those involving cultural and management practices leading to poor communication between them and their staff. Because our study examines cases in which discharge and readmission were to a general medicine service, it may not describe factors relevant to patients discharged from subspecialist or surgical services.
Implications for future QI efforts and research
Several clinicians we interviewed suggested that readmissions might be reduced by dedicating the services of a hospital professional, such as a nurse or case manager, to monitoring the clinical course of medically complex patients after discharge. A dedicated “transition coach” could clarify deficiencies in discharge paperwork, facilitate necessary follow-up appointments, liaise with staff at both the hospital and the SNF, or coordinate acquisition of necessary equipment. Prospective trials have demonstrated that such interventions can decrease readmission rates among hospitalized patients,22,23 but formal studies have not been carried out among cohorts of SNF patients.
Prior efforts to improve SNF-ED information sharing have focused on making sure that ED clinicians have important baseline information about patients transferred from a SNF.24,25 The experiences of SNF clinicians in our study suggest that important information also fails to make its way from ED providers to SNFs and that this failure results in unnecessary readmissions of relatively stable SNF patients. Thus, hospitals may be able to prevent SNF readmissions by creating lines of communication between EDs and SNFs and by ensuring that ED physicians and mid-level providers are familiar with the clinical capabilities of local SNFs.
Future research and QI work should also investigate approaches to care coordination that ensure that complex patients are placed in SNFs with resources adequate to address their comorbidities. Potential interventions might include increased use of SNF “liaisons,” who would evaluate patients in-person prior to approving transfer to a given SNF. As has been previously suggested,26 hospitals might also reduce readmissions by narrowing the pool of facilities to which they transfer patients, thereby building more robust, interconnected relationships with a smaller number of SNFs.
SNF clinicians identified areas for improvement at almost every point in the chain of events spanning hospitalization, discharge, and transfer. Among the most frequently cited contributors to readmissions were clinical instability at the time of discharge and omission of clinically important information from discharge documentation. Improved communication between hospitals, ED clinicians, and SNFs, as well as more thoroughly defined goals of care at the time of discharge, were seen as promising ways of decreasing readmissions. Successful interventions for reducing readmissions from SNFs will likely require multifaceted approaches to these problems.
Disclosure: This research was supported by a grant (#P30HS023554-01) from the Agency for Healthcare Research and Quality (AHRQ) and received support from Yale New Haven Hospital and the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (#P30AG021342 NIH/NIA).