A hospital-to-nursing home transfer process associated with low hospital readmission rates while targeting quality of care, patient safety, and convenience: a 20-year perspective.

Background: Safe patient transfer from hospitals to skilled nursing facilities (SNFs) is one of the most logistically challenging safety problems in the US medical system.

Problem: The authors describe a community that experienced inefficient transfers in the 1990s, spurring development of continuous quality improvement (CQI) methods to develop transfer forms and processes to improve efficiency.

Methods: The community established a Geriatric Forum for educational and process improvement purposes. Attendees consist of anyone involved with care of older patients in the community. Over the years, minor environmental changes forced periodic adjustments to transfer processes. The need for adjustment is identified by asking the simple question, "Have any problems occurred with transfers lately?" When problems are identified, forum attendees make process changes. The current forms and processes are discussed in detail.

Results: Initial improvement in efficiency of transfers also produced improvements in patient safety and quality of medical care according to periodic internal surveys. During 2009, this community's 30-day rehospitalization rate of patients discharged to a SNF was 14.75%, lower than any national or state average reported rate.

Conclusions: Developing hospital-to-SNF transfer methods focusing on the traditional CQI goals of efficiency, patient safety, and quality of care also yields lower hospital readmission rates. Because the methodology is that of CQI, a widely taught skill, similar programs could be established between any hospital and the SNFs to which it discharges patients. The particular examples of transfer forms and processes described might be helpful to other programs.