The Enhanced Care Program—improving Care Transitions from Hospital to Skilled Nursing Facilities and Reducing Readmissions

1Cedars Sinai Medical Center, Los Angeles, CA
2Cedars‐Sinai Medical Care Foundation, Beverly Hills, CA

Meeting: Hospital Medicine 2014, March 24-27, Las Vegas, Nev.

Abstract number: 707


Hospitals face significant challenges and opportunities related to the quality of care received by patients who are transferred from hospitals to SNFs. Ongoing pressure on hospitals to contain length of stay and the growing complexity and frailty of hospitalized patients put patients who are destined for SNFs at higher risk for post‐hospitalization complications and readmissions. Overall 30‐day readmission rates for Medicare patients is approximately 25% and with increasing financial penalties levied being upon hospitals for high readmission rates, greater attention to safe care transitions from hospital to SNFs is warranted.


The Cedars‐Sinai Health System’s Readmission Oversight committee created the Enhanced Care Program (ECP) to 1) Improve the quality and consistency of patients’ care transition from hospital to SNF, and 2) To provide additional clinical oversight for the care of these patients for the duration of their SNF stay.


A team of Nurse Practitioners (NP) was hired by the Cedars‐Sinai Health System to provide clinical care for patients discharged to 7 local SNFs, regardless of patients’ insurance. The team also included a pharmacist, a nurse educator, a medical director, and administrative support. All discharges from Cedars‐Sinai Medical Center to these 7 SNFs were eligible for enrollment. For each patient, the ECP medical director reached out to the SNF Attending MD and offered ECP’s services. ECP patient care protocol for enrolled patients included the following:

  • 1. An ECP NP visited the patient within 24 hours and reviewed the patient’s hospital medical records, SNF care plan, and spoke with the SNF staff, family members, and SNF Attending MD to make sure the care plan was clear and appropriate.
  • 2. The ECP Pharmacist reconciled the hospital’s discharge medication list with the active SNF medication list and discussed discrepancies with the ECP NP or SNF Attending MD;
  • 3. An ECP NP rounded on each patient on a weekly and PRN basis, communicating with the Attending MD at the time of each visit to discuss any changes in clinical condition and agree upon a workup and treatment plan;
  • 4. Any questions from the SNF staff throughout the week were first fielded by the ECP NP;
  • 5. Data was tracked 30‐day readmissions to Cedars‐Sinai Medical Center;


Over a 10‐month period, 754 patients were enrolled into ECP. Acceptance rate of ECP by the SNF Attending MDs exceeded 90%. 30‐day readmission rate for patients enrolled in ECP for this time period was 15.2%, compared to a baseline rate of 20.4% (25% reduction). Consistent communication amongst ECP team members, SNF staff, and SNF Attending MDs was key in order to manage high‐risk patients and allow them to remain at the SNF. As the penalty for 30‐day readmissions increases, the value and return on investment for innovative programs such as ECP will likely increase.

To cite this abstract:

Rosen B, Chang K, Hart K. The Enhanced Care Program—improving Care Transitions from Hospital to Skilled Nursing Facilities and Reducing Readmissions. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 707. Journal of Hospital Medicine. 2014; 9 (suppl 2). Accessed March 28, 2020.

« Back to Hospital Medicine 2014, March 24-27, Las Vegas, Nev.