title: Tools improve communication with SNFs, reduce readmissions.
abstract: A case management team at UPMC Presbyterian Shadyside Hospital in Pittsburgh has developed an initiative to improve communication between the hospital and skilled nursing facilities in an effort to reduce readmissions. The team interviewed readmitted patients, analyzed trends in readmissions and what caused them, and researched readmission prevention tools. They developed a risk tool that assesses a variety of issues and use it to help identify patients who are at risk for readmission. The tool covers comorbidities, psychiatric issues, polypharmacy issues, emergency department visits and hospitalization, and other issues. They created a discharge checklist that lists the tasks that should be done for every skilled nursing discharge.
mesh_terms: D019090:Case Management; D057189:Checklist; D003142:Communication; D006761:Hospitals; D019982:Organizational Case Studies; D010359:Patient Readmission; D010414:Pennsylvania; D018570:Risk Assessment; D012866:Skilled Nursing Facilities