SHM Converge Scientific Abstract ePoster Gallery-Evaluating Clinician Knowledge Around Hospital-to-Skilled Nursing Facility Transitions

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This resident-led quality improvement project evaluated hospital-to-skilled nursing facility (SNF) transitions, a high-risk process associated with frequent readmissions. The team surveyed 184 residents and 10 SNF providers across three urban SNFs to assess knowledge, confidence, and satisfaction with discharge communication. Resident response rate was 28.3% and SNF provider response rate was 100%.<br /><br />Results showed notable gaps. Residents felt only moderately confident about what to include in SNF handoffs; 59% reported confidence in knowing the required information, and although 65% said they knew the key elements to include, only 18% felt comfortable counseling patients about what to expect at an SNF. SNF clinicians were most satisfied with the clarity of the hospitalization summary, but they reported inconsistent communication of other important items such as medication reconciliation, wound care recommendations, follow-up referrals, pain regimens, and lab plans.<br /><br />In response, the team collaborated with SNF providers, case managers, nurses, and physicians to create an electronic health record-based discharge summary checklist (“smart phrase”) to standardize communication. The checklist was promoted through resident orientation, flyers, emails, paging reminders, and gamification between teams. Since its launch in November 2023, it has been used in 90 resident discharge summaries to SNF.<br /><br />The project found that residents often lack understanding of SNF capabilities and are unsure what information SNF teams need, while SNF providers want more complete and consistent handoff documentation. Next steps include post-intervention surveys to measure the checklist’s impact and additional education for residents on SNF care and patient counseling.

Asset Subtitle

Justin C. Zhang

Meta Tag

Author List Adrienne Strait, Bingyan Shi, Daniel Boctor, Diana Funk, Emily Marogi, Harry Cheung, James D. Harrison, Justin C. Zhang, Lillian Peng, Maham Awan, Norah Karlovich, Omid Shah, Priyanka A. Dutta, Rohini Kopparam, Tamara Sanchez-Ortiz, Theodore Peng, Ti

Category Research

Concept Hospital to Skilled Nursing Facility Discharge Handoff

Concept Discharge Summary

Concept Medication Reconciliation

Concept Transitional Care

Concept Wound Care

Distinguished Non-Finalist

Presenter Organization Ucsf

Presenting Author Justin C. Zhang

Track Transitions of Care

Keywords

hospital-to-SNF transitions

discharge communication

skilled nursing facility

quality improvement

resident education

handoff checklist

medication reconciliation

care transitions

readmission prevention

electronic health record

Hospital to Skilled Nursing Facility Discharge Handoff

Discharge Summary

Medication Reconciliation

Transitional Care

Wound Care