SHM Converge Scientific Abstract ePoster Gallery-Explaining Patient Experiences of the Hospital to SNF Care Transition

Pdf Summary

This qualitative study examined why older adults often have poor experiences when transitioning from hospital to skilled nursing facilities (SNFs). The authors noted that prior research had described these negative experiences but had not fully explained their causes within the complex hospital-to-SNF care system.<br /><br />Using a grounded theory approach, the researchers conducted 41 in-depth interviews with patients, caregivers, and clinicians, along with 30 hours of ethnographic observation at an urban academic medical center and a short-term rehabilitation SNF. Participants included adults age 65 and older, English-speaking, without dementia, plus their caregivers and hospital/SNF clinicians.<br /><br />The study found that poor transition experiences were driven by multiple interacting factors rather than a single cause. Key patient-related conditions included vulnerability, limited information, uncertainty, feeling unprepared, and resignation to the situation. These shaped patient behaviors such as taking a passive role, staying quiet to be “a good patient,” and struggling to manage or interpret information. This often led to outcomes such as lack of control and agency.<br /><br />Care team factors also played a major role. These included clinician training and practice norms, pressure to maintain throughput, and team-based care structures. These conditions contributed to processes such as checklist-driven care, communication gaps, delegating tasks and responsibilities, and limited direct connection with patients. While clinicians focused on medical stability and standardized workflows, patients often wanted more time, kindness, and clear expectations about recovery.<br /><br />Overall, the study concluded that suboptimal hospital-to-SNF transitions are multi-factorial. Improving them will require addressing patient, care team, and health system factors together, rather than relying on single interventions.

Asset Subtitle

James D. Harrison

Meta Tag

Author List Andrew D. Auerbach, Audrey Lyndon, James D. Harrison, Margaret C. Fang, Rebecca L. Sudore, Tasce Bongiovanni

Category Research

Concept Hospital to Skilled Nursing Facility Discharge Handoff

Concept Vulnerability

Concept Patient Agency

Concept Patient Control

Concept Communication

Distinguished Non-Finalist

Presenter Organization University of California San Francisco

Presenting Author James D. Harrison

Track Transitions of Care

Keywords

hospital-to-SNF transition

skilled nursing facilities

older adults

qualitative study

grounded theory

care transitions

patient vulnerability

communication gaps

care team factors

health system workflow

Hospital to Skilled Nursing Facility Discharge Handoff

Vulnerability

Patient Agency

Patient Control

Communication