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Key Clinical Questions

  • image Is each medication indicated for either an acute or chronic medical indication?

  • image If the drug does not have an indication for either an acute or chronic condition, was it prescribed to treat an adverse effect of another medication?

  • image Is the patient near the end of life?

  • image If you plan to discontinue a medication, does the drug require tapering rather than abrupt discontinuation?

  • image Are all underlying medical problems optimally treated with drug therapy according to established guidelines?

Review of patient safety issues and opportunities for quality improvement in skilled nursing facilities (SNFs) begins with the index hospitalization and the necessary steps to guarantee a safe transition from the referring hospital to the receiving facility. The transition of care from hospitalization to postacute care presents a significant risk to the safety of the older adult patient. Two key areas that require the clinician’s attention to ensure a safe transition of care are effective discharge communication including the discharge summary and the discharge medication reconciliation process. Safe and effective transitions reduce preventable readmissions and other adverse events.


The costs associated with the current transitions system illustrate the danger of care transitions and the need for a coordinated effort to ensure patient safety. Readmissions from skilled nursing facilities to the hospital increased by 29% from 2000 to 2006. Up to 24% of Medicare beneficiaries were readmitted to the hospital from a skilled nursing facility within 30 days at a cost of $4.34 billion in 2006. One-third of these occurred within just a week of initial discharge.

Older adults are at higher risk for readmission from skilled nursing facilities and more frequently experience care transitions. Patients who are frail or cognitively impaired often cannot actively participate in their transition processes and critical information (such as prehospital admission medications that were held) may be lost as a result.

Skilled nursing facilities are increasingly being held accountable for preventable readmissions. Similar to hospital metrics, Center for Medicare & Medicaid Services (CMS) is planning to use the 30-day readmission metric as a quality measure for skilled nursing facilities that provide postacute care (PAC). It is therefore important for individual clinicians to have a clear understanding of the PAC capabilities of their community SNFs. Clinicians and health care systems are creating preferred SNF networks based on readmission rate, length of stay, and other quality measures. Provider groups and hospitals are increasingly partnering with SNFs in quality improvement initiatives that help to ensure patient safety and reduce unnecessary utilization and readmissions.



Nurse and medical staffing ratios can be quite variable across facilities. Referring clinicians should be mindful that while the acuity level of PAC admissions has increased, nurse staffing ratios continue to remain far lower ...

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