title: SGIM-AMDA-AGS Consensus Best Practice Recommendations for Transitioning Patients' Healthcare from Skilled Nursing Facilities to the Community.
abstract: We assembled a cross-cutting team of experts representing primary care physicians (PCPs), home care physicians, physicians who see patients in skilled nursing facilities (SNF physicians), skilled nursing facility medical directors, human factors engineers, transitional care researchers, geriatricians, internists, family practitioners, and three major organizations: AMDA, SGIM, and AGS. This work was sponsored through a grant from the Association of Subspecialty Physicians (ASP). Members of the team mapped the process of discharging patients from a skilled nursing facility into the community and subsequent care of their outpatient PCP. Four areas of process improvement were identified, building on the prior work of the AMDA Transitions of Care Committee and the experiences of the team members. The team identified issues and developed best practices perceived as feasible for SNF physician and PCP practices to accomplish. The goal of these consensus-based recommended best practices is to provide a safe and high-quality transition for patients moving between the care of their SNF physician and PCP.
authors.affiliation: Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 North Lake Shore Drive - 10th floor, Chicago, IL, 60611, USA. LAL425@md.northwestern.edu.
authors.forename: Lee A
authors.initials: LA
authors.lastname: Lindquist
authors.affiliation: Division of Geriatric Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
authors.forename: Rachel K
authors.initials: RK
authors.lastname: Miller
authors.affiliation: Lahey Hospital and Medical Center, Burlington, MA, USA.
authors.forename: Wayne S
authors.initials: WS
authors.lastname: Saltsman
authors.affiliation: Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Carnahan
authors.affiliation: Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 North Lake Shore Drive - 10th floor, Chicago, IL, 60611, USA.
authors.forename: Theresa A
authors.initials: TA
authors.lastname: Rowe
authors.affiliation: Johns Hopkins University Division of Geriatric Medicine and Gerontology, Baltimore, MD, USA.
authors.forename: Alicia I
authors.initials: AI
authors.lastname: Arbaje
authors.affiliation: Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA.
authors.forename: Nicole
authors.initials: N
authors.lastname: Werner
authors.affiliation: Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.|Geriatrics Research Education and Clinical Center, James J Peters VA Medical Center, Bronx, NY, USA.|Research Institute on Aging, The New Jewish Home, New York, NY, USA.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Boockvar
authors.affiliation: California State University Institute for Palliative Care, San Marcos, CA, USA.
authors.forename: Karl
authors.initials: K
authors.lastname: Steinberg
authors.affiliation: Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
authors.forename: Shahla
authors.initials: S
authors.lastname: Baharlou
mesh_terms: D019985:Benchmarking; D014487:Centers for Medicare and Medicaid Services, U.S.; D003266:Continuity of Patient Care / Q000592:standards*; D006760:Hospitalization; D006801:Humans; D010351:Patient Discharge / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000191:economics; D011320:Primary Health Care / Q000458:organization & administration; D011787:Quality of Health Care / Q000592:standards*; D012866:Skilled Nursing Facilities / Q000191:economics / Q000458:organization & administration*; D000069341:Transitional Care / Q000191:economics / Q000458:organization & administration*; D014481:United States