Improving transitions for elderly patients

Connecting the hospital-based team with clinicians at SNFs


Transitions are always a time of concern for hospitalists, and the transition from hospital to skilled nursing facilities (SNF) is no exception.

“During the transition and in the 30 days after discharge from the hospital to a SNF, patients are at high risk for death, rehospitalization, and high-cost health care,” said Amber Moore, MD, MPH, a hospitalist at Beth Israel Deaconess Medical Center, and instructor of medicine, Harvard Medical School. “Elderly adults are especially vulnerable because of impairments that may prevent them from participating in the discharge process and an increase in the risk that information is lost or incomplete during the care transition.”

Dr. Amber Moore, a hospitalist at Beth Israel Deaconess Medical Center, and instructor of medicine, Harvard Medical School, Boston.

Dr. Amber Moore

To address this, she and several other physicians studied a novel video-conference program called Extension for Community Health Outcomes–Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at SNFs to help reduce patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs.

The results of their study suggest that this intervention significantly decreased SNF length of stay, readmission rate, and costs of care, she says; the model they used is reproducible and has the potential to significantly improve care of these patients. “Our model was hospitalist run and is a mechanism to help hospitalists improve care to their patients during the transition time and beyond,” Dr. Moore said. “Furthermore, in participating in this model, hospitalists have the opportunity to better understand the challenges that face their patients after discharge and learn from postacute care providers.”

Ideally, she would like to see the model spread to other hospitals; she says hospitalists are well positioned to set up this program at their institution. “I also hope that our study highlights the incredible opportunity for improvement in the care of patients during transition from hospital to SNF and encourages hospitalists to look for innovative ways to improve care at this transition,” she said.


Moore AB, Krupp JE, Dufour AB, et al. Improving transitions to post-acute care for elderly patients using a novel video-conferencing program: ECHO-Care transitions. Am J Med. 2017 Oct;130(10):1199-204. Accessed June 6, 2017.

Recommended Reading

Communication tools improve patient experience and satisfaction
The Hospitalist
Simplified HOSPITAL score predicts 30-day readmissions
The Hospitalist
How hospitalists can help reduce readmissions
The Hospitalist
Student Hospitalist Scholars: The importance of shared mental models
The Hospitalist
Sneak Peek: The Hospital Leader blog – Sept. 2017
The Hospitalist
Sneak Peek: The Hospital Leader blog – Oct. 2017
The Hospitalist
Using EHR data to predict post-acute care placement
The Hospitalist
Improving our approach to discharge planning
The Hospitalist
Identifying the right database
The Hospitalist
A game of telephone?
The Hospitalist
   Comments ()