Image of Joan Guzik, United Hospital Fund; Image credit: UHF
Joan Guzik, United Hospital Fund; Image credit: UHF

A survey of short stay residents discharged from skilled nursing facilities to home finds high praise for their transition teams but also highlights gaps in areas such as medication and care coordination.

The survey, from United Hospital Fund, a nonprofit healthcare advocate, queried 263 residents across eight New York skilled nursing facilities and 249 family caregivers between August and December 2020. The results revealed an overall positive view of the transition phase to home or community.

Fully 80% of respondents said they received and understood discharge instructions. More than 70% said they were able to access needed services, and 75% reported that home care services were delivered on time.

But at least two-thirds of discharged residents would have liked more help understanding their medication regimen and with drug side effects. In addition, less than half had received assistance with scheduling follow-up doctor appointments. And more than 40% reported that there was no follow-up call after discharge.

Referrals to social services needed

Other care transition concerns included a general lack of engagement on social needs such as affordable care, food, housing and transportation. What’s more, nearly half of those who were asked about these concerns said they nonetheless received no referrals to relevant services, the surveyors reported.

Only 50% of Medicare Part A beneficiaries successfully return to home or community after a short stay in a skilled nursing facility, according to the Centers for Medicare & Medicaid Services.

“Transitions of care are a precarious time for patients and their caregivers, and there has been limited focus on the needs of patients who are discharged to home following a short stay in a skilled nursing facility,” said co-author Joan Guzik, director of Quality and Efficiency at UHF. “This survey highlights a sizable opportunity for quality improvement efforts.” 

The survey is part of a two-year collaborative supported by the Mother Cabrini Health Foundation, a private charitable organization in New York state. Participating facilities will use the results to implement changes, and a follow-up report on their progress is planned, UHF said in a statement.

A downloadable version of the report can be found on UHF’s website.