Hospitalists Improving Transitions of Care Through Virtual Collaborative Rounding with Skilled Nursing Facilities – The HiToC SNF Study

From the 2022 HVPA National Conference

Sonia Dalal MD (Johns Hopkins Hospital), Ifedayo Kuye MD, Shaker Eid MD, Venkat Gundareddy MD


Many patients continue their post-acute care in settings such as a skilled nursing facility (SNF). One in four hospitalized Medicare patients are discharged to SNFs. These patients are generally the elderly or require more support than those discharged home, placing them at increased risk of clinical deterioration and rehospitalization. Moreover, 25% of patients discharged to SNFs were readmitted within 30 days costing Medicare $4.34 billion in 2006. In our intervention, patients discharged from two academic hospitals to one of six partner SNFs were reviewed weekly in a multi-disciplinary post-discharge telephone or video encounter that included a hospitalist from the hospital and medical and nursing leadership from the discussant SNF. The discussion reviewed the clinical status, discharge medications, treatment plan, and follow-up care of the discharged patients. The intervention took place from July 2021 to December 2021.


The aim of this intervention was to evaluate the impact of the program on improving the transition from the inpatient to the post-acute care setting and reducing readmissions from SNFs. We believed that the communication enabled by this program would augment the written discharge summary and in turn improve provider satisfaction on the safety of the transition and reduce medical errors.


Hospitalists were asked to assess for clinically significant errors within the discharge summary based on the discussion. Errors were classified as errors of omission when important information was not included and errors of commission when there was incorrect or conflicting information. SNF providers (n=13) and hospitalists (n=10) were also asked to complete a survey to assess the importance of the intervention in improving transitions of care and reducing readmissions.


During the study, 548 hospital patients were discussed in a post-discharge virtual encounter. After the discussions, hospitalists completed 510 discharge summaries assessments, of which 18% had errors of omission and 6.8% had errors of commission. The errors were then classified into one of five categories to include medication reconciliation, post-hospitalization follow-up plans, post-hospitalization treatment plan, patients baseline status or labs, or goals of care. Within errors of omission, 63.04% were due to post-hospitalization follow-up plans and within errors of commission, 77.14% were due to medication reconciliation. A survey of participating hospitalists (n=6) on a Likert scale (1 strongly disagree; 5 strongly agree) indicated the intervention was thought to improve transitions of care (4.5, SD 0.6) although there was less certainty that it reduced readmissions (3.5, SD 0.8). This view was shared by medical and nursing leadership at the SNFs (n=8); 4.6 (SD 0.5) on improving transitions of care and 3.9 (SD 0.6) on reducing readmissions.


Virtual collaborative rounding improves hospitalists knowledge of SNF clinical capabilities and thus can bridge the gaps during the transition of patients from the hospital to the post – acute care setting. Hospitalist-lead virtual collaborative rounding with SNFs improves transitions of care and identifies clinically significant errors in discharge summaries. Post-hospitalization follow-up plans, and medication reconciliation are the most common sources of errors identified in discharge summaries.

Clinical implications

This process improved the transition of care of patients from the inpatient to post-acute care setting. Open communication between the hospitalist and SNF providers allowed for gaps to be bridged and collaboration on ways to keep patients from being readmitted.

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