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SNFs: Opening the Black Box

Joseph G. Ouslander, MD, and Alice Bonner, PhD, GNP | December 1, 2013
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The Case

An 88-year-old woman was admitted to a skilled nursing facility (SNF) after a lengthy hospitalization for a small bowel obstruction, acute renal failure, and deep vein thrombosis. On arrival to the SNF, the patient was on 14 medications for her various conditions and remained mildly delirious. Nursing staff at the SNF expressed concerns about the level of care that could be provided, but they were told that the patient "didn't meet inpatient criteria any longer." During the first few days of the SNF visit, the staff continued to express concerns about the patient's overall health because she was not able to take all of her medications. The family was also concerned. The SNF physician saw the patient on the first day but not after that time. He continued to manage questions via phone with the nursing staff. About 3 days after admission, the patient developed a fever and shortness of breath, prompting a 911 call and transfer back to the acute facility. There, she was diagnosed and treated for pneumonia.

The Commentary

This case highlights the pressure on SNFs to manage sicker patients, which has recently increased substantially because of hospital penalties for high 30-day readmission rates. These penalties will grow, as will payment reforms such as bundled payments and Accountable Care Organizations (ACOs).(1) Because many SNFs depend on the higher payment rates for post-acute patients for financial solvency, they must respond to this pressure or face potentially devastating reductions in referrals from local hospitals. The pressure to manage sicker patients such as the one in the present case is a double-edged sword: On the one hand it is forcing better integration of acute and post-acute care and higher-quality care transitions; on the other, it is putting patients and SNFs at high risk for medical errors and other threats to patient safety.

Are SNFs prepared to safely manage complex patients? Based on publicly available data, the quality of care in many SNFs appears to be improving (2), but the medical and nursing capabilities to manage patients like the one presented are highly variable. This particular patient is at extremely high risk of complications due to residual symptoms of delirium, present in up to 40% of post-acute patients and associated with poor outcomes.(3) This patient is also at risk because of polypharmacy, which can contribute to delirium, hypotension, falls, and immobility along with its complications, such as pressure ulcers and, as may have occurred in this case, aspiration pneumonia. The net effect of this complexity and related complications is potentially preventable hospital readmissions of SNF patients, with further risks of the high incidence of hospital-acquired conditions. Close to 1 in 4 patients admitted to a SNF from a hospital are readmitted to a hospital within 30 days (4); a substantial proportion—up to 40%–67% of these hospital admissions—may be unnecessary.(5-7)

What strategies can help SNFs and medical care providers who work in them mitigate the threats to patient safety inherent in attempting to manage sicker patients like the case presented? There are many, as outlined in the Table. In addition to these general strategies, specific interventions could have helped prevent our patient's need for hospital readmission. The Hospital Elder Life Program (HELP) has been shown to be effective in managing delirium in hospitals, and all of its principles are applicable to the SNF setting.(8)

Our patient also came to the SNF taking 14 medications. Polypharmacy represents a major conundrum in managing complex older patients. Because of multi-morbidity and the proliferation of increasingly effective pharmacologic therapies and clinical practice guidelines that recommend them, prescribers have to carefully balance the risks of drug therapy against the benefits. Among geriatric patients at risk for delirium, judiciously discontinuing medications that could be causing or contributing to delirium may be effective. Meticulous medication reconciliation is essential at the time of SNF admission, and tools are available for this purpose.(9,10) The updated Beers Criteria (11) and the Screening Tool of Older Persons' potentially inappropriate Prescriptions ("STOPP") (12) offer useful guidance to prescribers on appropriate and safe drug therapy in the complex SNF patient population.

Among the strategies outlined in the Table, the one that has most consistently been associated with reduced hospital admissions is the use of teams of nurse practitioners (NPs) (or physician assistants [PAs]) and physicians in managing SNF patients.(13) Such teams often have more time dedicated to the SNF setting and are not only more experienced in post-acute care, but more available for on-site management of sicker patients—a critical factor in preventing hospitalizations rated as potentially avoidable.(6) This strategy, however, raises a problematic workforce issue: there are not enough NPs, PAs, or physicians dedicated to geriatric care to meet the need. There are no federal or state requirements for physicians or advanced practitioners to be onsite in Medicare-certified SNFs. The Centers for Medicare and Medicaid Services (CMS) only requires physician visits every 30 days for the first 3 months, then every 60 days thereafter. Typically, physicians or advanced practitioners visit complex SNF patients once or twice a week depending on acuity—but this practice is highly variable and a substantial number of SNFs have medical care providers visit less often. CMS requires that SNFs have a licensed nurse on every shift, but that is most often a licensed practical or vocational nurse (LPN or LVN). Facilities must have a registered nurse (RN) for 8 consecutive hours out of every 24 hours, 7 days a week, and the Director of Nursing must be an RN. However, SNFs typically have very few RNs, and the RNs are often assigned to documentation or other administrative tasks. Acute rehabilitation hospitals and long-term acute care hospitals have more regular availability of RNs and medical care providers, generally on daily basis.

Changes in reimbursement that value primary care and the increasing competition for residencies in many subspecialties may lead more physicians-in-training to enter careers in geriatric medicine with a focus on the SNF setting (so-called SNFists). The same pressures forcing SNFs to manage sicker patients are also incentivizing hospitals to create post-acute networks and deploy well-trained hospitalists in SNFs, which may also help address the physician shortage. But, much more is needed. Direct care workers in SNFs, as well as RNs and nurse leaders, must be adequate in number and well educated. These fundamental staffing principles are necessary but not sufficient to change behavior and improve care. SNF leadership must foster a culture of quality and person-centered care and facilitate the implementation of quality improvement initiatives that focus on common patient safety concerns. CMS is currently drafting a regulation outlined in the Affordable Care Act that will require SNFs to have a Quality Assurance Performance Improvement (QAPI) plan; this plan must outline how the facility will achieve their quality and safety goals to meet CMS requirements.(14)

INTERACT (Interventions to Reduce Acute Care Transfers) is an example of a quality improvement program that provides direct care workers, nurses, other SNF clinicians, medical care providers, and families with the tools necessary to manage sicker patients in the SNF setting without hospital transfer whenever safe and feasible. The program resources are free for clinical use at Implementation of INTERACT has been associated with a 17%–24% reduction in all-cause hospitalizations.(15) The program includes four key strategies: (i) identifying conditions early before they become severe enough to require hospital transfer (could our patient's high risk or signs of pneumonia have been identified earlier?); (ii) managing some changes in condition without transfer when safe and feasible (was our patient unstable enough to need immediate transfer?); (iii) augmenting communication and documentation (was information transfer from the hospital suboptimal?); and (iv) improving advance care planning and use of palliative and hospice care as an alternative to hospitalization when appropriate (was our patient at the end of life and would palliative care have prevented the transfer?). Incorporating the INTERACT program and others like it into health information technology will greatly enhance its value and ability to enable SNF staff to "do the right thing at the right time" by providing structured evaluations, alerts, real-time decision support, and better documentation of critical information necessary to prevent medical errors.

This case represents the challenges of, but also the opportunities for, improving the care of complex patients in SNFs. Taking advantage of the opportunities will help us meet the goals of the "triple aim": improved care, better health, and more affordable care.(16)

Take-Home Points

  • The pressure on SNFs to manage sicker patients will continue to increase, which will result in both challenges to patient safety as well as opportunities to improve care.
  • Evidence, expert guidance, and programs are available and should be utilized to manage high-risk conditions such as delirium, polypharmacy, and fall risk in complex SNF patients.
  • Teams of physicians and nurse practitioners (or physician assistants) can be highly effective in managing complex SNF patients and preventing unnecessary hospitalizations where they are available.
  • INTERACT is a quality improvement program with related clinical practice tools that can help SNF staff and medical care providers manage some complex patients without hospital transfer when safe and feasible.
  • Incorporation of quality improvement programs and related tools into health information technology will improve the value of these programs by providing structured evaluations, alerts, real-time decision support, and better documentation of critical information necessary to prevent medical errors.

Joseph G. Ouslander, MD Professor and Senior Associate Dean for Geriatric Programs Interim Chair, Department of Integrated Medical Sciences Charles E. Schmidt College of Medicine Professor (Courtesy), Christine E. Lynn College of Nursing Florida Atlantic University

Alice Bonner, PhD, GNP Associate Professor, School of Nursing Faculty Associate, Center for Health Policy Bouvé College of Health Sciences Northeastern University, Boston, MA

Acknowledgments Dr. Ouslander is the lead developer of the INTERACT quality improvement program. He has support for INTERACT projects from the National Institutes of Health (1R01NR012936), the Centers for Medicare and Medicaid Services, The Commonwealth Fund, the Patient Centered Outcomes Research Institute, Medline Industries, and Westcom, Inc. Dr. Ouslander and his wife Lynn Ouslander are part-owners of INTERACT Training, Education, and Management Strategies, a start-up company related to Florida Atlantic University. Dr. Bonner receives support from the National Institutes of Health (1R01NR012936) and The Commonwealth Fund for work on the INTERACT program.


1. Ouslander JG, Berenson RA. Reducing unnecessary hospitalizations of nursing home residents. N Engl J Med. 2011;365:1165-1167. [go to PubMed]

2. Nursing Home Compare. Baltimore, MD: Centers for Medicare & Medicaid Services. [Available at]

3. Kiely DK, Jones RN, Bergmann MA, Murphy KM, Orav EJ, Marcantonio ER. Association between delirium resolution and functional recovery among newly admitted postacute facility patients. J Gerontol A Biol Sci Med Sci. 2006;61:204-208. [go to PubMed]

4. Mor V, Intrator O, Feng Z, Grabowski DC. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29:57-64. [go to PubMed]

5. Saliba D, Kington R, Buchanan J, et al. Appropriateness of the decision to transfer nursing facility residents to the hospital. J Am Geriatr Soc. 2000;48:154-163. [go to PubMed]

6. Ouslander JG, Lamb G, Perloe M, et al. Potentially avoidable hospitalizations of nursing home residents: frequency, causes, and costs. J Am Geriatr Soc. 2010;58:627-635. [go to PubMed]

7. Walsh EG, Wiener JM, Haber S, Bragg A, Freiman M, Ouslander JG. Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and Home- and Community-Based Services waiver programs. J Am Geriatr Soc. 2012;60:821-829. [go to PubMed]

8. The Hospital Elder Life Program (HELP). [Available at]

9. INTERACT. Boca Raton, FL: Florida Atlantic University. [Available at]

10. Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. Medication discrepancies upon hospital to skilled nursing facility transitions. J Gen Intern Med. 2009;24:630-635. [go to PubMed]

11. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616-631. [go to PubMed]

12. Hamilton H, Gallagher P, Ryan C, Byrne S, O'Mahony D. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med. 2011;171:1013-1019. [go to PubMed]

13. Konetzka RT, Spector W, Limcangco MR. Reducing hospitalizations from long-term care settings. Med Care Res Rev. 2008;65:40-66. [go to PubMed]

14. QAPI: Quality Assurance & Performance Improvement. Baltimore, MD: Centers for Medicare & Medicaid Services. [Available at]

15. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project. J Am Geriatr Soc. 2011;59:745-753. [go to PubMed]

16. Ouslander JG. The triple aim: a golden opportunity for geriatrics. J Am Geriatr Soc. 2013;61:1808-1809. [go to PubMed]


Table. Strategies to Improve Patient Safety in Managing Complex Post-Acute Patients in the SNF Setting.

Enhanced SNF leadership and culture of safety and quality AHRQ Nursing Home Survey on Patient Safety Culture allows facilities to enter and benchmark data on safety culture
TeamSTEPPS—an AHRQ evidence-based program on improving teamwork for patient safety QAPI for Nursing Homes—CMS has produced tools and resources to assist nursing homes with developing QAPI plans
Use of teams of physicians and nurse practitioners (or physician assistants) Clinical Collaboration Toolkit—updated review of how to structure a collaborative nursing home practice with physician/advanced practitioner teams
Bolstering the workforce in the SNF setting Leading Age Center for Applied Research Web page has several resources on workforce development
Adherence to guidelines on transitions in care National Transitions of Care Coalition has guidelines and resources on care transitions
Targeted quality improvement programs to manage high risk conditions such as delirium, polypharmacy, and fall risk CMS will be posting new tools on specific topics such as polypharmacy, falls, and delirium on their QAPI website in the next few months
Individual state quality improvement organizations (QIOs) may also have resources on their websites Consult your state QIO's Web site
Advancing Excellence in America's Nursing Homes has many tools and resources on these and related topics
Quality improvement programs and related clinical practice tools specifically focused on reducing preventable hospital transfers, admissions, and readmissions INTERACT
Coalitions or networks that enhance collaboration among SNFs, emergency departments, and hospitals State Action on Avoidable Rehospitalizations is an IHI collaborative that began in three states. Early learnings have led to adoption of cross-continuum teams in other states and regions as well
QIOs now have nursing home quality care collaboratives (NHQCCs) in every region Also consult your state QIO's Web site
Increasing use of health information technology to improve communication and documentation across settings of care Many tools and resources have been developed and posted on the Advancing Excellence Web site
The American Health Information Management Association has a long term–post acute care interest group
This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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