SNF Discharge Communication Must Focus on Patient Education

The SNF discharge process from inpatient care to recovery at home should be characterized by patient education, caregiver engagement, and follow-up from SNF staff, according to a new report from United Hospital Fund (UHF).

In doing so, skilled nursing facilities (SNFs) may increase the odds of fewer SNF or hospital readmissions and better overall outcomes, the report authors wrote.

“Transitions of care, when a patient moves from one care setting to another, are a vulnerable time,” UHF wrote in the report’s executive summary. “Inadequate preparation for transitions frequently places frail and otherwise vulnerable older adults at risk of overuse of acute care services, declining health, permanent residency in a skilled nursing facility (SNF), and high levels of stress, anxiety, and dissatisfaction.”

Typically, less than half of patients return home or to a community-based service after a short stay in a SNF, UHF said, citing figures from the Centers for Medicare & Medicaid Services.

That could be due to fragmented patient discharge processes, previous reporting from UHF has found. As part of a learning collaborative with eight SNFs across the country, UHF found that patient education has been considerably lacking from SNF discharge plans, causing some bumps in the road for those transitioning to home or community-based settings.

This latest report, published also as part of that learning collaborative, found some successful interventions that improved the SNF discharge process. Successful SNFs engaged in:

• Better medication patient education
• Better patient education about chronic disease management
• Streamlined discharge planning to meet individual patient needs
• Use of health IT and video technology to support patient education
• Involvement of patient and caregivers in the discharge planning process

These initiatives were all supported by three key patient-provider communication strategies. Foremost, those involved in patient discharge used patient teach-back, a technique in which providers ask patients or caregivers to repeat instructions back to them. That repetition allows providers to identify miscommunication or misunderstanding, and also reinforces messaging for patients or caregivers.

Additionally, those providers followed up with patients and caregivers 72 hours after discharge to repeat any patient education or care instructions.

Finally, organizations issued post-discharge patient or caregiver surveys that asked how the discharge process went. Most surveys asked patients or caregivers whether staff described medications and gave instructions for taking them, as well as whether providers described symptoms or side effects patients might experience once home.

These interventions, most of which centered on patient education, were highly successful, the UHF report found. Efforts to explain medications helped more patients understand their prescriptions. The rate of patients who reported understanding their prescriptions jumped from 57 to 98 percent after facilities focused on medication education.

Meanwhile, patient understanding of potential symptoms or problems they may experience at home increased from 70 to 93 percent after SNFs ramped up efforts, UHF added.

Of course, success wasn’t as straightforward as “trying harder,” UHF suggested, and improving discharge processes for SNF patients isn’t as simple as implementing patient education strategies. The UHF report acknowledged the myriad challenges beleaguering SNFs, including fragmented reimbursement exacerbated by low pandemic patient volumes; poor staffing; and pandemic-era limits on family visitation that affect caregiver education.

“More attention and resources are needed to support our long-term care infrastructure in the United States, including both facility-based care and home- and community-based services,” said Anthony Shih, MD, UHF president, said in a statement. “The difficulties that patients experience when transitioning home from care in a skilled nursing facility are an example of where targeted improvement efforts can make a difference. UHF has a longstanding interest in and commitment to improving transitions of care.”

SNFs successful at revamping their discharge processes executed process mapping to understand the different roles of various disciplines within the four walls of the facility. Additionally, they standardized processes, used an interdisciplinary team-based approach, and conducted early and tailored patient follow-up after discharge.

“As the population ages and the prevalence of chronic disease rises, safe, effective, and person-centered transitional care plans will become even more essential,” Joan Guzik, UHF director of quality and efficiency, Quality Institute, and lead author of the toolkit, said in the press release. “The SNF interventions implemented in our project, and explained in the toolkit, led to marked improvement in our partners’ ability to ensure that patients’ needs were met as they went home.”