Over one in five Medicare patients discharged to skilled nursing facilities (SNFs) are re-hospitalized within 30 days of discharge. Poor communication between the hospital and SNF upon hospital discharge is frequently cited as the most common cause of readmission.

The goal of this program was to assess the ability of a weekly post-discharge hospitalist led virtual rounding program to augment the written discharge summary sent to SNFs.

Two academic hospitals and six SNFs in Baltimore, MD.

Hospitalists and medical directors or directors of nursing from the partner SNF.

During weekly encounters, the hospitalist and SNF providers discussed the clinical status, discharge medications, treatment plan, and follow-up care of all discharged patients. The intervention took place from July 2021 to December 2021.

During the study, 544 patients were discussed in a post-discharge virtual encounter. After the discussions, hospitalists identified clinically significant errors in 124 discharge summaries. A survey of participating hospitalists and SNF medical and nursing leadership indicated the intervention was thought to improve care transitions.

Our innovation was successful in identifying errors in discharge summaries and was thought to improve the transition of care by participating SNF and hospitalist providers.