Hospitalists enter SNFs to snuff out readmissions

Outreach program helps improve outcomes after an acute hospitalization.

Where: Palomar Medical Center in Escondido, Calif., and affiliated nearby skilled nursing facilities (SNFs).

The issue: Reducing readmissions among patients discharged from the hospitalist service to a SNF.


In 2015, the hospitalists at Palomar Medical Center, who are partners with CEP America, were analyzing their performance. “Of course, the number 1 issues were readmission rates and quality of care,” said hospitalist Arben Dashi, MD. “We looked into factors that could really improve the outcome after an acute hospitalization. A few physicians in our group that had experience in a SNF in the past expressed, ‘Why don't we approach [SNFs] with outreach?’” The group did just that and, a year later, 8 hospitalists now follow their group's patients when they are discharged to any of 12 different SNFs in the area.

How it works

“We assign a physician to that facility that goes to the facility at least twice a week and follows every one of the patients that we discharge to that particular facility,” explained Dr. Dashi, who himself sees patients at 2 SNFs. The SNFs contract with CEP America to have the hospitalists see patients in their facilities.

At the SNF, the hospitalists not only visit the recently discharged patients and keep in touch with any treating subspecialists but also work with the SNF staff to provide them with any needed information or skills.

“We focus on however we can improve patient care at the facility,” Dr. Dashi said. “We go over what to monitor throughout the stay, bringing their awareness to what to really focus on. If the patients have any medical devices they are not familiar with, we train them on those.”

Hospitalists have worked with SNF staff on issues such as prevention of urinary tract infections or Clostridium difficile, and they participate in monthly quality assurance meetings at the SNFs.


From the time the collaboration launched in August 2015 to July 2016, readmissions among patients discharged from the hospitalist service to the 12 SNFs dropped an average of 12%, CEP America reports. During that same time period, the 30-day readmission rate for patients discharged from the hospital to any SNF was 9% on average; for those who were followed by the hospitalists, it was below 1%.

Dr. Dashi has noticed other benefits, such as the potential to reduce hospital length of stay for some patients. “The patient's waiting on a culture or a test result that determines the length of therapy or potential change in therapy, for instance, an antibiotic regimen for a patient with sepsis from a complicated UTI or pyelonephritis but otherwise stable for discharge....Handing that off to one of our SNF colleagues reduces hospital stay by at least 1 or 2 days,” he said.

SNF follow-up by hospitalists may also help avoid admissions entirely for ED patients who are determined to require a level of care that can be provided at the SNF, for example, intravenous fluids and/or antibiotics, Dr. Dashi added.


One of the main challenges facing the initiative was getting buy-in from outpatient physicians who might otherwise have cared for these patients. “There were some physicians who questioned, ‘Why is the hospitalist going into the community?’” Dr. Dashi reported.

The hospitalists dealt with that issue by targeting only the patients who really needed their services. “The care continuum is our driving force,” said Dr. Dashi. If patients have an established relationship with primary care physicians who visit the SNF, the hospitalists don't interfere. “Patients that don't have primary care physicians, we follow all those patients,” he said.

The hospitalists have demonstrated to the other physicians how their expertise and communication with the hospital can be helpful, especially for patients with complex, comorbid conditions, he added.

How patients benefit

“There are certain patients who really make our effort worthwhile,” said Dr. Dashi, who went on to describe such a case. “She was so sick the first day I saw her at the SNF after she was discharged by one of my colleagues, I thought I was probably going to send her back to the hospital.” Instead, after intensive effort at the SNF, the patient became healthy enough for discharge. “As I'm going to see a new admission, I'm walking in the hallway, she's chasing behind me with a walker.... She said, ‘I'm leaving tomorrow. I want to give you a hug,’” Dr. Dashi said.

Next steps

The hospitalists have recently started another SNF-based collaboration, for patients recovering from cardiac surgery. With hospitalist supervision, the SNF now takes such patients when they still have drain tubes in place. “We have reduced the inpatient hospital stay for this particular [type of] patient by taking them to SNF. Lines get removed there by the surgeon and they get more rehab than they would be able to get in an acute care setting,” said Dr. Dashi.

Words of wisdom

Dr. Dashi encourages other hospitalists to get involved in the SNFs that care for their patients after hospitalization. “Getting them to the level that they're ready for discharge shouldn't be the goal. The goal should be that patients should fully recover,” he said.