WIHI: Mobilizing Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations

Date: February 27, 2014


  • Laurie Herndon, MSN, GNP-BC, Director of Clinical Quality, Massachusetts Senior Care Foundation
  • David Gifford, MD, MPH, Senior Vice President, Quality and Regulatory Affairs, American Health Care Association
  • Annette Crawford, Administrator, Stafford Healthcare at Ridgemont
  • Marie Schall, Director, Institute for Healthcare Improvement
In the world of health care improvement, and in society at large, talking about skilled nursing facilities (SNFs) and long-term can be a tough subject. When a loved one moves in to a nursing home, they’re usually quite elderly, and it's often the last move they'll make of this kind before dying. So, whether because of this association or because other sectors of health care tend to get more attention, the hard work that’s going on to ensure that all types of SNFs, and nursing homes, deliver high-quality and patient-centered care, has been somewhat obscured. We’d like to help change this by zeroing in on one aspect of the work.
This WIHI looks at new developments with better coordination and communication between SNFs, local hospitals, and various community stakeholders, to reduce unnecessary transfers of patients to acute care settings. These avoidable admissions or readmissions can come from short-term-stay SNFs or long-term ones, from assisted living residences or rehab facilities.
Unpacking what’s behind unnecessary transfers and what better, safer, actions might be taken has been the focus of IHI’s STAAR initiative and is captured in one of a series of STAAR How-to Guides: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations.
Our guide on the learning and momentum everyone can build upon from STAAR was IHI’s own Marie Schall, who’s also the first to point to the rich activity and resources available from Laurie Herndon and the widely recognized INTERACT program.
Another huge resource is the American Health Care Association, which is mobilizing SNFs across the US to do their part to reduce readmissions within 30 days by 15% by 2015. David Gifford also spoke to these efforts.
And, then there’s the amazing example of Kitsap County in the state of Washington, where Annette Crawford’s SNF has played a leading role building a new kind of coalition across the continuum of care to ensure that patients get the right care in the most appropriate setting.




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