New research reveals that information sharing challenges are hampering care transitions from hospitals to skilled nursing facilities (SNFs). LeadingAge CAST helped guide the study, which has raised concerns about patients’ experiences during care transitions. To solve this challenge, said the study’s authors, broader hospital-led efforts are needed, ideally supported by IT infrastructure improvements and incentives for high-quality care transitions.

The study’s intent was to determine the current state of information sharing, after a decade of health IT infrastructure and new incentives to promote coordination between hospitals and SNFs. The study’s timeframe was before the pandemic, between January 2019 and March 2020.

“Information Sharing Practices Between US Hospitals and Skilled Nursing Facilities to Support Care Transitions” shares the full results.

The survey of SNFs yielded responses from 471 hospital-SNF pairs. SNFs provided their experience with their two highest-volume referring hospitals. SNFs reported that key information was often lacking in several ways:

• Missing (functional, mental, and behavioral status as well as whom to contact at the hospital with follow-up questions),
• Delayed (often arriving after the patient), and
• Difficult to use (discharge documents with duplicative and extraneous information).

 Only 14% of hospital-SNF pairs reported excellent performance on all three dimensions of information sharing, while 30% were at or below the mean performance on all dimensions.

Potential Solutions

Having a hospital clinician on site at the SNF was associated with more complete, timely, and usable information sharing, said the report. Shared clinicians were the only significant factor associated with better information sharing across all three dimensions.

The study pointed to other factors that should prompt better care transitions yet were not consistently associated with better information sharing., These factors include having a hospital-SNF collaborative or having a hospital participate in an accountable care organization.

“Shared clinicians represent a potential strategy to improve information sharing but are costly,” noted the report’s authors. “New payment models such as accountable care organizations may offer a more scalable approach but were only associated with more timely sharing.” 

CAST Technology Selection Tool

If you are looking at technology to improve your organization’s care transitions, please refer to the LeadingAge CAST Shared Care Planning and Coordination Technology Selection Tool. It includes a white paper, interactive guide, selection matrix, online selection tool, and provider case studies to help you choose the best technology to meet your organization’s needs.

The LeadingAge CAST Health Information Exchange (HIE) Technology Selection Tool may be helpful as well. The white paper, interactive guide, online selection tool, selection matrix, and case studies will help you choose the right HIE for your organization. 

These tools are among eight LeadingAge CAST Technology Selection Tools.