Enterprise Risk Management (ERM) Human Capital Legal & Regulatory Patient Safety/Clinical Care

Improving Transfer Communication between Hospitals and Post-Acute Facilities

Challenged by transfers of care between hospitals and post-acute care facilities? You are not alone. Administrators and nursing leadership in both settings struggle. What previously required only few key pieces of information about a patient has evolved into a complex process with multiple opportunities for failure. Risks exist that are associated with inaccurate or incomplete transfer of information affecting resident and patient safety, resulting in the potential for harm.

Patients with multiple comorbidities are discharged quickly from the hospital setting to post-acute or long-term care. The goal is to provide quality care and services within the established payor’s parameters while at the same time preventing the dreaded readmission to the hospital.

Post-acute care settings include long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs) and home health agencies. Readmissions are costly, result in financial penalties, and most importantly, can be a traumatic experience for the patient, resulting in increased morbidity and mortality. For the resident, the hospital and the facility, paramount is reliable, effective communication.


In addition to the receiving facility being ill-prepared to meet the specific needs of the patient, inadequate handoff communication can result in the following: 

  • Medication mishaps or discrepancies
  • Unmet expectations of patients and their family
  • Unwanted conditions such as pressure ulcers
  • Confusion with payor-source resulting in billing mishaps
  • Behavior management needs beyond the scope of the facility
  • Failure to meet special dietary needs
  • Readmission to the hospital


Using an enterprise risk management framework, the following can mitigate the risks of resident harm and enhance effective handoff communication between acute care facility and subsequent providers.

Operational – A successful transfer of care from acute care to skilled nursing starts with early communication. Typically, post-acute care facilities follow one of two approaches to assess a referral from the hospital. In the first model, a nurse conducts a quick, on-site clinical assessment of the patient, which includes a review of the medications, plan of care and the payor source. This assessment also considers whether patient needs can be met. In the second model, the marketing/admissions coordinator presents the information to the receiving facility’s clinical team. The diagnosis, payor source, plan of care, medications, and discharge plans are reviewed by the teams in both scenarios.

Conducting a clinical assessment ensures the person on paper is the person who arrives at the facility. Failure to obtain pertinent information increases the risk of readmission. For example, the hospital patient may be receiving dialysis. If this information is not relayed to the subsequent care facility, they will have to scramble to set up dialysis services. Be certain a system is in place to obtain the most current information. Establishing a good relationship with hospital discharge planners is key for a successful outcome.

Human Capital – Hospital lengths of stay have decreased, while the acuity level for patients being discharged to post-acute care facilities has increased dramatically. Accepting a medically complex resident with a condition with which the facility is inexperienced can result in failure to meet resident expectations and a rapidly deteriorating condition that sends the resident back to the hospital. The hospital discharge planner must relay as much information as possible including equipment and psycho-social details.

It is the responsibility of the receiving facility to ensure that staff is prepared to meet the new resident needs. Some facilities partner with vendors, clinics or outpatient services to provide specialized services such as wound care. In some instances, the clinic or vendor provides training for the staff and assesses competency levels. These partnerships provide opportunities for post-acute care facilities to broaden their range of services.

Also, many post-acute care and skilled nursing facilities have nurse practitioners on-site to reduce rehospitalizations. They are available to quickly intervene and provide treatment in the event a resident experiences a change in condition. Early recognition of conditions such as pneumonia can allow the resident to stay at the facility and receive treatment. A study conducted in Missouri that placed advanced practice registered nurses in nursing homes found a decrease of hospitalizations by 33% and a Medicare savings of $1,376 per person.

Financial – Readmissions at skilled nursing facilities result in costly consequences for hospitals and SNFs. In 2018, 73% of skilled nursing facilities and 83 % of hospitals received financial penalties related to readmission rates (Rau 2019; Castelluci 2018). Not only does the SNF suffer financial penalties but it risks experiencing a reduction in referrals. Financial pressures on hospitals and SNFs result in hurried discharges of medically complex and sometimes unstable patients. Open communication regarding patient status and plan of care is necessary for a successful transfer of care and to decrease the risk of readmission.

In one analysis, based on SNF data from 2006 Medicare claims merged with the Minimum Data Set (MDS), “23.5 % of SNF stays resulted in rehospitalization within 30 days of the initial hospital discharge. The average Medicare payment for each readmission was $10,352 per hospitalization, for a total of $4.34 billion. Of these rehospitalizations, 78 % were deemed potentially avoidable, and applying this figure to the aggregate cost indicates that avoidable hospitalizations resulted in an excess cost of $3.39 billion (78% of $4.34 billion) to Medicare” (Mor, et al. 2010).

Clinical/Patient Safety – When a resident is transferred from an acute care setting to a post-acute care facility, important clinical safety considerations include accurate baseline assessment, accurate medication history and reconciliation, and following evidence-based practices, among others.

Before or at the time an individual is admitted to the post-acute care facility, effective handoff communication must occur. A structured handoff tool (e.g., situation-background-assessment-recommendation or SBAR) can make certain all necessary criteria are addressed. If such a tool is not in use, facilities can develop a script that includes elements needed to safely care for the individual such as:

  • Diagnosis and treatment
  • Medical history
  • Procedures performed
  • Current condition
  • Recent vital signs
  • Allergies
  • Medication history and reconciliation (last dose and next dose).
  • Skin assessment including any risk factors, existing incisions, lesions or pressure injuries, and information needed to appropriately choose specialty surfaces
  • Fall risk assessment
  • Questions to aid with bed assignment (e.g., for those with fall risk or wandering tendencies)

A combination of handoff communication methods such as an electronic tool or written document coupled with a telephone call is often the most effective. Relying solely on an electronic method of handoff communication results in a lack of confirmation that the information was received and understood, and the lack of opportunity to ask questions.

Once the resident is admitted to the post-acute or skilled nursing facility, an assessment must take place as soon as possible to document any conditions present on admission and to reconcile medications. The care plan must be customized to reflect these conditions and make certain appropriate interventions are in place as soon as possible.

An individualized evaluation and plan of care associated with the diagnosis and treatment are essential. Assessments should be performed and documented following the standard of care and regulatory requirements. By focusing on the individual’s diagnosis and condition, care providers can customize assessments using the minimum standards for frequency and criteria as a baseline. More detailed care plans can then be developed accordingly. Documentation of the resident’s condition along with observations and monitoring are critical for communication among members of health care teams. Such documentation is also beneficial in the event of quality review or litigation.

Part of the transfer communication process should include ensuring a common understanding of circumstances for which the provider must be notified, such as the presence of certain symptoms, or changes in vital signs, laboratory values, or other elements of the assessment.

Strategic – Many facilities are equipped to care for a population that includes b skilled nursing residents and subacute rehabilitation patients. To serve its clientele between acute hospitalization and return to the SNF, a facility may offer rehabilitation services. If the SNF has begun admitting patients for rehabilitation without corresponding changes to staffing, education, and equipment, the potential exists for resident and employee harm.

Managing expectations of patients, residents and families is a balancing act. Make certain all parties are aware of the capabilities and limitations while receiving care at the facility. Beware of the risks of including promises in contracts and admission agreements (i.e., don’t promise the resident will not fall or will be under 24-hour observation if not the case). Evaluate the facility’s printed materials, website and social media platforms for any statements that might be subjective such as the “best” care, or “guarantees” of safety.

When the transfer process fails and less than adequate care and services result, the facility’s reputation and brand are at significant risk. In this climate of social media and real-time sensationalism, it only takes one or two bad stories from a disgruntled family member to ruin a facility’s good reputation.

Legal/Regulatory – The legal and regulatory risks link directly to the financial risks. This is especially true for post-acute communities where compliance and quality of care are tied directly to reimbursement and payment. Also, post-acute care settings are subject to full transparency in that any breach of compliance, no matter how insignificant, can be perceived by the public as egregious and unacceptable.

Health care is one of the most regulated industries or at least that is the way it feels for the facility boards and administrators. Most cannot sustain repeated risks of non-compliance with federal, state and local regulations. Add the costs of negligent claims and workers’ compensation costs and a post-acute care community is tipped into financial collapse.

The facility must comply with all of the regulations that impact the transition of the patient to the post-acute care facility. Also, the facility should establish a robust internal process to self-monitor, assess and audit compliance. Where non-compliance is identified, the facility should have a methodology to enact improvements using performance improvement tools and methodologies such as Lean Six Sigma, Plan-Do-Study-Act (PDSA), INTERACT II and others. (CMS/QAPI 2020).

Technology – In communicating during handoffs, the receiving facility must be made aware of the appropriate equipment and technology needed to care for individuals with certain conditions based on their condition (e.g., bariatric equipment, lifts, sit to stand devices, infusion pumps). Education related to the individual’s diagnosis, treatment and plan of care is essential and can be accomplished through in-person or computer-based methods.

An electronic medical record interface is another important aspect of care transition. Methods for the transmittal of patient transfer information vary with telephone, verbal and electronic communication.


An ERM approach to managing the risk of transitions of care between post-acute and long-term facilities is a way to proactively identify, prioritize and mitigate the potential uncertainties of this very complex process. ERM enhances the multi-disciplinary process of decision making based on reliable data and information. ERM methodology is supported by the most senior levels of the organization while holding accountable all three lines of defense: the front-line team members, middle management and senior leadership.


Castellucci, M. (2018, November 28). Most skilled nursing facilities penalized by CMS for readmission rates. Modern Healthcare.

QAPI resources. (2020, February 11). Centers for Medicare and Medicaid Services Homepage | CMS. Retrieved May 11, 2020, from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/qapiresources

Flynn, M. (2017, October 11). Advanced practice nurses cut hospitalizations from SNFs by almost half. Skilled Nursing News.

Grissinger, M. (2016, April). From the hospital to long-term care: protecting vulnerable patients during handoffs. P&T41(4), 204-205. 


Health Services Advisory Group. (n.d.). Skilled nursing facility care coordination toolkit. Retrieved May 11, 2020, from https://www.hsag.com/care-coord-tools

The Joint Commission. (2012). Transitions in care: the need for a more effective approach to continuing patient care. Retrieved May 11, 2020, from https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/hot_topics_transitions_of_carepdf.pdf?db=web&hash=CEFB254D5EC36E4FFE30ABB20A5550E0

Landi, H. (2019, August 14). Patient handoffs to post-acute care providers still largely a manual process, hindering effective care coordination. FierceHealthcare. https://www.fiercehealthcare.com/tech/patient-handoffs-to-post-acute-care-providers-still-largely-a-manual-process-report

Mor, V., Intrator, O., Feng, Z., & Grabowski, D. C. (2010). The Revolving Door Of Rehospitalization From Skilled Nursing Facilities. Health Affairs, 29(1), 57–64. doi: 10.1377/hlthaff.2009.0629

Rau, J. (2019, November 1). New round of Medicare readmission penalties hits 2,583 hospitals. Kaiser Health Newshttps://khn.org/news/hospital-readmission-penalties-medicare-2583-hospitals/

Stratis Health. (n.d.). Quality improvement toolkit for emergency department transfer communication measures. Retrieved May 11, 2020, from https://www.stratishealth.org/documents/ED_Transfer_QI_Toolkit_Communication_Measures.pdf

Nancy Connelly, RN, BA, CPHRM, DFASHRM is a risk management consultant with RCM&D, an independent insurance advisory firm in Baltimore. She is an active member of the American Society for Healthcare Risk Management (ASHRM), and is 2020 Chair of the ASHRM Forum News Task Force.
Kenita Hill, MSA, CPHRM, LNHA, LPN, is vice president of operations at ServarusRM. A licensed nursing home administrator with a background in long-term care that spans more than 25 years, she is responsible for the operations of the risk management program at ServarusRM, including on-site risk management audits and training at SNFs and ALFs across the country.

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