Rethinking transitions of care: An interprofessional transfer triage protocol in post-acute care

Skilled Nursing Facilities Modify the Relationship Between Depressive Symptoms and Hospital Readmissions but Not Health Outcomes Among Older Adults

“…SNFs (compared to routine discharges home) reduced readmissions among patients with high depressive symptoms but did not modify the risk that depressive symptoms pose for short-or long-term falls or mortality. Therefore, discharging a patient with high depressive symptoms to an SNF compared to less intensive care settings might align with provider incentives to avoid readmission penalties (Patel et al, 2017), but would not optimize patient health and functioning in the vulnerable post-hospital period.…”

“…Nonetheless, referrals for post-acute care remain profitable, if costly for patients. A provision of the Protecting Access to Medicare Act of 2014 created a value-based purchasing program for SFNs, making 30-day readmission rates from long-term care facilities publicly available and financially de-incentivized, like readmissions from the community (Patel et al, 2017;Wilson, 2014). These payment policies may increase the likelihood that discharge decisions are based on financial rather than clinical factors, the latter of which align care needs with the appropriate post-hospital settings.…”