The power of SNF-to-hospital case reviews

4 minute read

The power of SNF-to-hospital case reviews

< 1 minute read

El Camino Hospital holds monthly meetings with local SNFs to identify gaps in care and develop solutions.

The Issue

Acute care hospitals and SNFs have not traditionally collaborated to improve the overall transition of patients. The relationship between the two entities has typically focused on marketing and availability of beds and not quality of care. It is estimated that one in five patients readmitted within 30 days come from SNFs. This lack of care coordination and key information exchange with comprehensive handoffs results in a transition from the hospital to SNF which is highly unpredictable and puts the most vulnerable and fragile patients at risk for readmission.


El Camino is a non-profit hospital in Mountain View, CA. It has 399 beds and serves a primarily affluent and educated population, many of who are non-English speaking or have English as a second language. Their transitions program began in 2012 and is influenced by the Care Transitions Program.

What We Tried

We began meeting with local nursing homes in 2011 to look at how we can best work together to improve the transition of patients between the acute and post-acute setting and reduce readmissions. Many successful initiatives were implemented as a result of this collaboration. We currently host a luncheon meeting once a month, with 12-15 nursing homes usually present. In an effort to reduce readmissions and improve the overall transition, we focus on three objectives: improve collaboration, communication, and competency (the 3 C’s). At the monthly meetings we complete case reviews for every 7-day readmission in the past month. Utilizing a standard case review form completed by both hospital and SNF, we discuss each case with the entire group – talking about why the patient was admitted to the hospital, status at time of discharge, events that occurred at the SNF that led up to why they were readmitted. The purpose is not to blame anyone, but instead identify gaps that can help prevent other patients from readmitting.


These meetings have really opened up channels of communication that didn’t exist before. It’s much quicker and easier to identify gaps in care and implement solutions. They have also created a sense of collaboration so that if a SNF has a problem they feel comfortable calling us directly to discuss.

Three direct improvements came from these meetings. The first is a checklist that our discharge nurses use to ensure the SNFs are receiving all of the documentation they need with the patient. It’s essentially a cover letter to standardize the transfer packet because SNFs were receiving inconsistent information in the past.

The second is a form the SNFs fill out when they send a patient to the emergency department. It summarizes pertinent information about the patient such as why the patient is getting sent to the emergency room, the current code status, the contact person at the SNF, their last set of vital signs, and any other relevant information. This helps our ED team quickly get a sense of what’s going on with a patient without having to sort through the stack of paperwork that the SNF usually sends.

The third improvement was an antipsychotic consent form that our hospital physicians can provide when patients are getting discharged to a SNF. In the past, SNFs had to get a separate consent from their own doctors. This meant that, if a patient was admitted on a Friday, they may not see a SNF doctor until Monday—so they wouldn’t have access to their antipsychotic medications for three days. Our doctors can now consent them for 72 hours after discharge.

These are only some of the solutions that have developed from these monthly meetings. We’re currently testing out a nurse-to-nurse phone handoff as well. Overall these meetings have increased our collaboration with SNFs, improved satisfaction, and ultimately improved care for our patients.


At first, the SNFs thought the luncheon was a marketing opportunity to get more patients and sent their marketing representatives. We had to emphasize that this was a clinical meeting where we needed a clinical team to do case reviews.

The case reviews are not about blame or specific patients. We keep patients anonymous and try to make the environment as open as possible. There are many things that are broken with the system that we can all work together to fix.

Program Challenges: Coordinating with Outpatient Care

Topics: After-hospital care, Identifying causes of readmission, Measuring and improving

Collaborator (Non-Members): Mae Lavente

Organizational Background

Organization Name: El Camino Hospital

Location: El Camino Hospital, Mountain View, CA, United States

Organization Type: Non-profit