A New York urban medical center and its collaborative of skilled nursing facilities focused on improving the communication between the entities and ended up reducing readmissions by 40%, initial findings from a new study revealed. 

“We aim to continue to discover other factors and decrease readmission for chronically ill nursing home patients at our urban medical center,” Montefiore Medical Center physician Nidhi Shah, M.D., concluded. 

The facilities targeted their “lack of verbal communication” regarding wound care orders, nutrition and feeding orders, comprehensive discharge summary and advance directives to help drive the changes.

They then developed a plan that included a warm handoff between the discharging team and receiving team at the SNFs, created a comprehensive discharge packet for residents, improved the hospital course in the discharge summary and created a standardized system for discharging residents to SNFs. 

Using the new methods, the facilities were able to decrease 30-day readmission rates by 40%, according to the study. 

“By improving communication between two facilities, we achieved our aim in the initial PDSA Cycle by implementing our palliative care skills,” Dr. Shah wrote. 

The research project is ongoing. Initial findings were published in the February issue of the Journal of Pain and Symptom Management.

This story has been updated.