Overview | Post-Acute Care Transitions Toolkit

How to Use:

The Society of Hospital Medicine (SHM) Post-Acute Care Toolbox provides a wealth of resources to help optimize the transitions of care process between short-term acute care hospital stays (STACHs) and Skilled Nursing Facilities stays (SNFs). The approach of the Toolbox is based on the principles of quality improvement applied to this specific transition. The interventions within the Toolbox are derived from both evidence-based medicine and the experiences of institutional experts. In addition, the Toolbox includes a section on resources, programs and innovations developed by professional societies, governmental agencies and businesses. This information is important to understand when engaging in process improvement in this area. The Toolbox is organized into the following sections:


After short-term acute care hospitalization, about one in five of Medicare beneficiaries requires continued, specialized treatment in one of the three typical Medicare Post-Acute Care settings (Figure 1):

  • Inpatient Rehabilitation Facilities (IRFs)
  • Long-Term Acute Care Hospitals (LTACHs)
  • Skilled Nursing Facilities (SNFs)

More Information: Click to expand

Each of these settings provides valuable services based on specific patient needs and varying capabilities. The initial STACH stay is the entry point in the process ultimately leading to the post-acute care (PAC) stay needed to recover from their illness (Figure 2).4 The time spent in the post-acute care can be at multiple settings, requiring several transitions of care between the STACH, Post-Acute Care Facilities, and in the community setting.

Below is more information on each of these Post-Acute Care Settings:


Figure 1.

Long-Term Acute Care hospitals (LTACH), Skilled Nursing Facilities (SNFs) chart

Courtesy of Jing Li, MD, MS, Center for Health Services Research, University of Kentucky

More Information: Click to expand

Inpatient Rehabilitation Facilities (IRFs) specialize in intensive rehabilitation care aiming to help patients to function outside of an inpatient environment. Long-Term Acute Care Hospitals (LTACHs) specialize in the treatment of medically complex patients who require a prolonged length of stay (LOS) of at least 25 days. Both IRFs and LTACHs are classified as acute care hospitals and can be either freestanding or hospital-based facilities. Skilled Nursing Facilities (SNFs) are not considered hospitals and provide treatment and continuing observation of medically stable patients who require short-term skilled care (e.g. Medicare fully covers 21 days) such as nursing or rehabilitation services in an institutional setting. Nearly 90 percent of the PAC facilities are free standing, often located in nursing homes. The remainder are located in acute care hospitals and continuing care retirement communities.


Figure 2.

Click to expand: Importance of PAC services differs by condition and patient severity chart

More Information: Click to expand

The readmission rate from the SNF post-acute care setting has received much attention. In 2010, researchers found that nearly one in four Medicare inpatients were readmitted from SNFs 30 days after discharge.5 In the past, Medicare tracked hospital readmissions from SNFs for five conditions: congestive heart failure, respiratory infections, urinary tract infections, septicemia and electrolyte imbalance. The rates for these potentially preventable readmissions has remained steady at 19 percent from 2000 to 2011.3 This figure lowered to 17.3 percent by the third quarter of 2013. These findings were in the setting of increased scrutiny by Medicare, focused on increasing PAC spending, especially for SNF care.7 This year Medicare revised the measure of re-hospitalizations for SNFs to include eight new conditions in addition to the original five conditions. Using this new metric there was a small improvement in SNF readmissions, a 0.8 percent decrease, between 2011 and 2012.8

Currently, many STACHs are partnering with their SNF providers to reduce readmissions due to the Hospital Readmissions Reduction Program (HRRP) mandated by the Patient Protection and Affordable Care Act, and in anticipation of payment reforms promoting across-setting accountability. These partnerships face daunting problems attempting to address the discontinuities created by facility-to-facility transfer of inpatients with multiple medical needs and a potentially substantial decrement in clinical resources, including staff devoted to patient care at SNFs compared to STACHs.


Post-Acute Care Transition Resources

National and Regional Programs Addressing Acute Care Hospital and SNF Transitions:

State Action on Avoidable Rehospitalizations (STAAR) Program Click to expand


The Institute for Healthcare Improvement (IHI) created a quality initiative program, STAAR. The program assists with improving safe transitions on a regional and national level. Having three main sites — Massachusetts, Michigan and Washington — the initiative works with patients, families and caretakers to provide guidance and support to improve transitions and reduce overall readmissions. STAAR aims to cut the cost of readmissions in a two-part strategy. The first engages participants in a collaborative learning process that analyzes best practices and experience-based improvements. Then, STAAR uses the new tools and procedures and implements them at a state-level for continuing education and resources.


Interventions to Reduce Acute Care Transfers (INTERACT) Click to expand


INTERACT is a quality improvement program focusing on strategies to reduce the frequency of readmissions to long-term care facilities.


Quality Improvement Organizations, ICPC: Click to expand


The Quality Improvement Organizations offer institutions an initiative that will give them access to information and shared knowledge from hospitals, nursing homes, home health agencies, dialysis centers, hospices and palliative care facilities. QIO plans to measure these rates by collecting data from appropriate sites about hospital admissions and readmissions. To ensure the most accurate results, QIO has data collection at a local level as well to improve quality of care.


Minnesota Reducing Avoidable Readmissions Effectively (RARE): Click to expand


RARE is a campaign based in Minnesota whose goal was to prevent 4,000 hospital readmissions by December 31, 2012. Minnesota required a statewide effort toward achieving their triple aim of improving population health, the experience and affordability of care. The RARE Campaign came to an official close in June 2014. The campaign will share quarterly data from the Minnesota Hospital Association with participating hospitals.


State of Maryland Efforts: Click to expand


Maryland has a coordinated state wide effort underway, including a specific priority on Hospital to Skilled Nursing Home Facility transitions.

Below are helpful links based on the Maryland efforts:

  1. Readmissions Playbook
  2. November 14, 2013 Statewide Meeting
  3. Reducing Readmissions 2


Health Information Exchange (HIE) and Regional Health Information Organization (RHIOs) Examples: Click to expand


Improving Massachusetts Post-Acute Care Transfers (IMPACT) is designed to improve care transitions for hospitalized patients using an enhanced electronic Universal Transfer Form (UTF) and electronic health information exchange. IMPACT will analyze approximately 100,000 patient transfers in a year. The device will lower avoidable transfers and readmission for nursing home patients, especially.


Keystone Beacon Community has designed a new health information exchange (HIE) making it easier than ever for nurses and other caretakers to share patients’ information with or without an electronic health record. It is important for caretakers to have access to patient’s information recorded from critical long-term and post-acute care facilities to ensure the safest care transitions possible. There is already a tool used to collect data in the Pennsylvania region known as Keystone Health Information Exchange, or KeyHIE. Physicians from other Pennsylvania hospitals have deemed it necessary to offer more complete assessments.


Nursing Facility and Other Post-Acute Care Specific Programs and Resources:

AMDA: The Society for Post-Acute and Long-Term Care Medicine Click to expand


The Society for Post-Acute and Long-Term Care Medicine is the national professional association of medical directors, attending physicians, and other professionals practicing post-acute and long-term care medicine and committed to the continuous improvement of patient care. AMDA provides education, advocacy, information and professional development to enable its members to deliver quality post-acute and long-term care.

AMDA also provides a useful Transitions of Care Clinical Practice Guideline (CPG) that can be found on their website here:


Leading Age: Click to expand


Leading Age is an association for non-profit senior services that provide a continuum of care from adult day care to long-term care settings. The organization’s state chapters provide services that may be useful in determining resources available to patients transitioning from hospital to SNF, as well as educational programs and assistance with understanding regulatory and advocacy issues that are important to understand when working within this transition.


American Health Care Association (AHCA): Click to expand


AHCA is an association of long-term and post-acute providers (proprietary and not-for-profit organizations) that advocates quality care in these care settings. This organization has a wealth of educational, regulatory and advocacy information regarding long-term and post-acute care that maybe helpful to for teams improving transitions from hospitals to the post-acute care setting.


Quality Assurance Performance Improvement (QAPI) (CMS): Click to expand


QAPI programs are designed to improve patient safety and should always involve the analysis of clinical care. After data is collected, it is reevaluated to determine best practices and measure goals. The development and designation of leadership roles to distinguish training responsibilities and representation of resources are vital components to a QAPI program’s success. The implementation of a feedback system that can record, read and assess all data that has been collected is essential for comparing and determining best practices and then generating Performance Improvement Projects (PIPs). PIPs are developed in response to specific clinical situations and designed to address their dangers and propose ways to overcome the challenges faced. Once data collection and reporting has been completed, analysis will be undertaken and a plan of action will then be designed to summarize the problematic areas within the hospital or care setting.

CMS has invested heavily in developing protocols and tools to improve cross-setting transitions and post-acute protocols to improve detection of early changes in clinical status and support interventions in PAC without escalating to Emergency Departments. A novel and large-scale example of this effort is the CMMI Round 1 Innovation Challenge Grant awardee, University of North Texas, Brookdale Senior Living and Loopback Analytics.

More Information below:




Electronic Health Records (EHR): Click to expand


Although implementation and functional ability of electronic health records in the LTC/SNF is highly variable by facility, most EHRs used in this setting are focused on being able to submit administrative data for CMS payment and quality requirements (e.g. MDS data for SNF prospective payment). However with increasing linkages to STACHs and interest in ACOs, some EHR products are now beginning to incorporate clinical EHR functions, especially for the physician care component.

LTC/SNFs are not included by the Health Information Technology for Economic and Clinical Health (HITECH) Act which incentivizes hospitals and physicians to adopt certified EHRs through the meaningful use program. However, physicians working in the LTC environment are considered ambulatory providers and are subject to the meaningful use rules- unless they have applied for hardship exemptions. Some of EHR vendors are “modularly certified” for certain Office of the National Coordinator for Health Information Technology (ONC) EHR measures and have, for instance, the ability to send a Transitions of Care Summary in compliance with meaningful use Stage Two requirements.


Pharmacy Services: Click to expand


Pharmacy services for SNFs provided in long-term care facilities are often serviced by off-site pharmacies. This may lead to delays in getting specialty medication delivered to the SNF setting for transitioning patients. These pharmacies often provide a consultant pharmacist to review the resident/patient medication list to prevent medication adverse events in compliance with LTC regulations. Therefore, acute care providers should not assume that the SNF has its own dedicated 24 hour pharmacy and pharmacy staff to troubleshoot problems with medications that occur on the transfer.


Telemedicine and Nursing Homes: Click to expand


Dr. David C. Grabowski has designed a study analyzing the cause and frequency of nursing home patient hospitalizations. In this study, Dr. Grabowski proposed a new method of diagnosis. Using a two-way video conferencing device, Telemedicine, healthcare providers can consult with patients and families directly, without having to direct them to the ER. Insufficient on-call physician hours often lead to patient hospitalization due to lack of convenience in nursing homes, but implementing Telemedicine may cut costs for hospital transfers and lower readmissions rates. The greatest restriction that comes from this is Medicare compliance. Dr. Grabowski suggests a payment reform and including Telemedicine in Medicare bundling.


Advancing Excellence: Click to expand


The Advancing Excellence in America’s Nursing Homes Campaign is a program created by the Advancing Excellence in Long-Term Care Collaborative. The aim of this project is to ensure complete quality of care to all nursing home patients.


Evercare: Click to expand


Optum Palliative and Hospice Care gives patients and families care while facing terminal illness. They are dedicated to assisting and helping patients and families’ lives as comfortable and peaceful as possible. Optum is continuingly recognized for high standards of care from the Community Health Accreditation Program, or CHAP.


LTC trend tracker: Click to expand


The American Health Care Association offers LTC Trend Tracker. The software tracks data to help standardize, and compare in-house reports. The LTC Trend Tracker can also help formulate tendencies and opportunities for institutions and help toward progressing forward.


Journals Relevant to Skilled Nursing Facility Care

Here are few journals that offer articles that are relevant to Skilled Nursing Facility Care:

SHM’s Post-Acute Care White Papers

SHM has developed three new white papers to help you learn more about Skilled Nursing Facilities (SNFs), Long-Term Acute Care Hospitals (LTACHs) and Inpatient Rehabilitation Faculties(IRFs).

References: Click to expand


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Post-Acute Care Transitions Implementation Toolkit Project Team

This implementation toolkit is supported in part by a non-educational sponsorship from IPC and Kindred Healthcare


The Post-Acute Care Transitions (PACT) Implementation Toolkit is an online resource for visitors to the Society of Hospital Medicine’s website. All content and links have been reviewed by the Post-Acute Care Transitions Implementation Toolkit Project Team, however the Society of Hospital Medicine does not exercise any editorial control over content associated with the external links that have been made available via this website and does not endorse the external content provided.