The Enhanced Care Program: Impact of a Care Transition Program on 30-Day Hospital Readmissions for Patients Discharged From an Acute Care Facility to Skilled Nursing Facilities.

BACKGROUND: Increased acuity of skilled nursing facility (SNF) patients challenges the current system of care for these patients.

OBJECTIVE: Evaluate the impact on 30-day readmissions of a program designed to enhance the care of patients discharged from an acute care facility to SNFs.

DESIGN: An observational, retrospective cohort analysis of 30-day hospital readmissions for patients discharged to 8 SNFs between January 1, 2014, and June 30, 2015.

SETTING: A collaboration between a large, acute care hospital in an urban setting, an interdisciplinary clinical team, 124 community physicians, and 8 SNFs.

PATIENTS: All patients discharged from Cedars-Sinai Medical Center to 8 partner SNFs were eligible for participation.

INTERVENTION: The Enhanced Care Program (ECP) involved the following 3 interventions in addition to standard care: (1) a team of nurse practitioners participating in the care of SNF patients; (2) a pharmacist-driven medication reconciliation at the time of transfer; and (3) educational in-services for SNF nursing staff.

MEASUREMENT: Thirty-day readmission rate for ECP patients compared to patients not enrolled in ECP.

RESULTS: The average unadjusted, 30-day readmission rate for ECP patients over the 18-month study period was 17.2% compared to 23.0% among patients not enrolled in ECP (P < 0.001). After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P < 0.001). These effects were robust to stratified analyses, analyses adjusted for clustering, and balancing of covariates using propensity weighting.

CONCLUSIONS: A coordinated, interdisciplinary team caring for SNF patients can reduce 30-day hospital readmissions.