A survey of short-stay residents discharged from skilled nursing facilities to home highlights gaps in discharge planning, especially in medication management and care coordination.

The United Hospital Fund (UHF) surveyed 263 residents and 249 family caregivers, August through December 2020, across eight New York skilled nursing facilities. The results, provided by the nonprofit healthcare advocate, revealed an overall positive view of the transition to home.

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

Addressing social needs, including affordable care, food, housing, and transportation was another care transition concern. In addition, nearly half of those looking for resources 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.

Download a version of the report here.