SHM Converge Scientific Abstract ePoster Gallery-Improving Long-Term Care Placements Through Acute Care Hospital and Skilled Nursing Facility Collaboration: A Case Conferencing Model

Improving Long-Term Care Placements Through Acute Care Hospital and Skilled Nursing Facility Collaboration: A Case Conferencing Model

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This report describes a structured case-conferencing model designed to improve long-term care (LTC) placement for hospitalized patients with complex medical, psychiatric, and behavioral needs who were repeatedly denied by skilled nursing facilities (SNFs). At a large safety-net acute care hospital, these patients often remained hospitalized for months, creating significant alternate level of care (ALC) burden and capacity strain.<br /><br />To address the lack of a standardized referral pathway, the hospital partnered with an 800-bed SNF that had expertise in behavioral management. The two institutions created recurring multidisciplinary case conferences using a standardized one-page template to present each high-barrier case. The process also included clear communication of acceptance criteria and a rapid return pathway so the SNF could transfer a patient back to the hospital if needs exceeded its capacity.<br /><br />From April to October 2025, 17 long-stay patients were reviewed; all had been declined by other SNFs. Outcomes included 11 discharges to the partnering SNF, 1 patient accepted and awaiting a bed, 1 patient accepted but later discharged home by family preference, and 4 declines due to smoking or forensic history. The model enabled 2,965 total ALC days to be transitioned to lower levels of care, with a mean hospital length of stay of 351 days, mean ALC stay of 270 days, and mean time from conference to discharge of 44 days. The readmission pathway was used once, and the patient was later safely discharged home.<br /><br />The authors conclude that standardized case conferencing, early partnership with behaviorally experienced SNFs, and recurring multidisciplinary review can improve placement rates, reduce prolonged hospitalization, and strengthen trust between facilities.

Asset Subtitle

Ian Fagan

Meta Tag

Author List Ian Fagan, Isabella Brandes, Jonathan Meldrum, Ravindra Amin, Samantha F. Sanders

Category Innovations

Concept Skilled Nursing Facility

Concept Long-Term Care Placement

Concept Multidisciplinary Case Conference

Concept Behavioral Expertise

Concept Placement

Distinguished Non-Finalist

Presenter Organization NYU Langone Grossman School of Medicine

Presenting Author Ian Fagan

Track Transitions of Care

Keywords

long-term care placement

skilled nursing facilities

case conferencing

alternate level of care

hospitalized patients

behavioral management

multidisciplinary review

safety-net hospital

prolonged hospitalization

discharge planning

Skilled Nursing Facility

Long-Term Care Placement

Multidisciplinary Case Conference

Behavioral Expertise

Placement