SHM Converge Scientific Abstract ePoster Gallery-Collaborative Rounding With Skilled Nursing Facilities and Hospitalists

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The HiToC SNF Study evaluated whether hospitalist-led virtual collaborative rounding with skilled nursing facilities (SNFs) could improve transitions of care for patients discharged from the hospital to post-acute care. This intervention was motivated by the high risk faced by SNF-bound patients: about one in four hospitalized Medicare patients are discharged to SNFs, and many experience clinical deterioration, rehospitalization, and communication gaps after discharge. The study also aimed to determine whether direct communication between hospitalists and SNF providers could supplement written discharge summaries, improve provider satisfaction, and reduce medical errors.<br /><br />From July to December 2021, the team implemented virtual collaborative rounding between hospitalists and SNF staff. Surveys were completed by hospitalists and SNF providers to assess the perceived value of the program. The intervention was designed to identify errors in discharge summaries and improve coordination around follow-up plans and medication reconciliation.<br /><br />Results showed that the process improved the transition of care from the inpatient setting to post-acute care. Open communication allowed hospitalists and SNF providers to identify and bridge gaps in care, and to collaborate on ways to reduce readmissions. The most common discharge summary errors involved post-hospital follow-up plans and medication reconciliation.<br /><br />Survey responses were positive. Participating hospitalists reported that the intervention improved transitions of care (mean 4.5/5), though they were less certain it reduced readmissions (mean 3.5/5). SNF medical and nursing providers shared similar views, rating transition improvement at 4.6/5 and readmission reduction at 3.9/5.<br /><br />Overall, the study concluded that virtual collaborative rounding improves hospitalists’ understanding of SNF capabilities, strengthens communication, and helps identify clinically significant discharge errors.

Asset Subtitle

Sonia Dalal

Meta Tag

Author List Ifedayo Kuye, Shaker M. Eid, Sonia Dalal, Venkat P. Gundareddy

Category Innovations

Concept Virtual Collaborative Rounding

Concept Transitional Care

Concept Hospitalist

Concept Skilled Nursing Facility

Concept Discharge Summary

Distinguished Finalist

Presenter Organization Johns Hopkins Hospital

Presenting Author Sonia Dalal

Track Transitions of Care

Keywords

hospitalist-led rounding

skilled nursing facilities

transitions of care

virtual collaborative rounding

post-acute care

discharge summary errors

medication reconciliation

readmission reduction

provider communication

SNF study

Virtual Collaborative Rounding

Transitional Care

Hospitalist

Skilled Nursing Facility

Discharge Summary