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Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach
  1. Kirstin A Manges1,2,
  2. Roman Ayele3,
  3. Chelsea Leonard3,
  4. Marcie Lee3,
  5. Emily Galenbeck3,
  6. Robert E Burke2,4
  1. 1National Clinician Scholar, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  2. 2Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
  3. 3Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
  4. 4Section of Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Kirstin A Manges, National Clinician Scholar, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; kirstin.manges{at}pennmedicine.upenn.edu

Abstract

Background Despite the increased focus on improving patient’s postacute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this study was to observe processes used to prepare patients for postacute care in SNFs, and to explore differences between hospital-SNF pairs with high or low 30-day readmission rates.

Design We used a rapid ethnographic approach with intensive multiday observations and key informant interviews at high-performing and low-performing hospitals, and their most commonly used SNF. We used flow maps and thematic analysis to describe the process of hospitals discharging patients to SNFs and to identify differences in subprocesses used by high-performing and low-performing hospitals.

Setting and participants Hospitals were classified as high or low performers based on their 30-day readmission rates from SNFs. The final sample included 148 hours of observations with 30 clinicians across four hospitals (n=2 high performing, n=2 low performing) and corresponding SNFs (n=5).

Findings We identified variation in five major processes prior to SNF discharge that could affect care transitions: recognising need for postacute care, deciding level of care, selecting an SNF, negotiating patient fit and coordinating care with SNF. During each stage, high-performing sites differed from low-performing sites by focusing on: (1) earlier, ongoing, systematic identification of high-risk patients; (2) discussing the decision to go to an SNF as an iterative team-based process and (3) anticipating barriers with knowledge of transitional and SNF care processes.

Conclusion Identifying variations in processes used to prepare patients for SNF provides critical insight into the best practices for transitioning patients to SNFs and areas to target for improving care of high-risk patients.

  • healthcare quality improvement
  • process mapping
  • qualitative research
  • transitions in care
  • health services research
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Footnotes

  • Twitter @Kirstin_Manges, @BBurkeMD

  • Contributors Study concept and design: KM, RA, CL, ML and REB. Data collection: RA, CL, ML and EG. Analysis and interpretation of data: KM, RA, CL, ML, EG and REB. Preparation of the manuscript: KM, RA, CL, ML, EG and REB.

  • Funding This study was funded by Agency for Healthcare Research and Quality (T32HS026116-02) and VA Health Services Research & Development (HSR&D) (Career Development Award).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the local IRB at the study team’s primary site: seven sites ceded to the primary IRB, while two sites obtained separate approvals.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data sharing not applicable as no datasets generated and/or analysed for this study. All data relevant to the study are included in the article or uploaded as supplementary information. Additional information may be obtained by emailing kirstin.manges@pennmedicine.upenn.edu.

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