Abstract
30-day readmissions for patients at skilled nursing facilities (SNF) are common and preventable. We implemented a readmission review process for patients readmitted from two SNFs, involving an electronic review tool and monthly conferences. The electronic review tool captures information related to preventability and factors contributing to readmission. The study included 128 patients, readmitted within 30 days from 1 October 2015 through 1 May 2017, at a tertiary care academic medical centre in Boston, MA, and two partnering SNFs. There was a discrepancy in preventability rating between SNF and hospital reviewers, with 79.7% of cases rated not preventable by the SNF, and 58.6% by the hospital. There was moderate positive correlation between the hospital's and SNFs' preventability ratings (r(s)=0.652, p<0.001). In most cases, the SNF reviewers felt that no factors contributed (57.8%), and hospital reviewers felt that issues with end-of-life planning (14.1%) and medical complexity (12.5%) were major factors. Despite the lack of strong correlation between SNF and hospital responses, several cross-continuum quality improvement projects were developed. We found that implementation of a SNF readmission review process employing bidirectional review by SNF and hospital was feasible, and facilitated systems-based improvement in the transition from hospital to postacute care.