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P20 - Reducing Readmissions from Skilled Nursing Facilities: A Quality Improvement Project

Poor communication contributes to unnecessary transfers of skilled nursing facility (SNF) residents to acute care hospitals (Ashcraft & Owen, 2017). Approximately 25% of admissions from SNFs are deemed to be avoidable (Ashcraft & Owen, 2017). The Centers for Medicare and Medicaid Services impose penalties for patients who are readmitted within 30 days of discharge (Haley et al., 2016). Two small community hospitals were challenged with readmissions from local skilled nursing facilities. After performing a literature search, the team decided to standardize handoff communication to the skilled nursing facilities verbally and in the discharge paperwork. The situation, background, assessment, recommendation (SBAR) method of communication was designed to ensure critical information regarding patients was not missed. We hypothesized that an SBAR report from the hospitals to the SNFs would reduce readmission rates.

A retrospective cohort design study with pre- and post-intervention arms was conducted. From September 2019 to February 2020, patients discharged from the two small community hospitals were enrolled in the pre-intervention group. The standardized SBAR report was created in collaboration with the post-acute care coordinator, managers, bedside nurses at all facilities, directors of nursing, and the clinical nurse specialist. In September 2020, the SBAR to the SNFs was implemented, and patients discharged to the SNFS were enrolled.

The pre-intervention group contained data from September 2019 to February 2020 and had an average of 9.35 readmissions per month. The post-intervention group contained data from September 2020 to February 2021 and had an average of 6.3 readmissions per month. This data yielded a 32.6% reduction in 30-day readmissions from SNFs with a p


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