Overview | Post-Acute Care Transitions Toolkit

How to Use:

The SHM Post-Acute Care Toolbox provides a wealth of resources to help you optimize the transitions of care process between STACHs and SNFs. The approach of the Toolbox is based on the principles of quality improvement applied to this specific transition. The interventions within the Toolbox are derived from evidence based medicine and also on expert and institutional experiences. In addition the Toolbox also includes a section on resources, programs, and innovations developed by professional societies, governmental agencies, and business that are important to understand when engaging in process improvement in this area. We have organized this Toolbox into:


After short-term acute care hospitalization (STACH), about 1 in 5 of Medicare beneficiaries require continued, specialized treatment in the three typical Medicare Post Acute Care Facility settings: Inpatient Rehabilitation Facilities (IRFs), Long Term Acute Care hospitals (LTACHs), and Skilled Nursing Facilities (SNFs) (Figure 1). Each of these settings provides valuable services based on specific patient needs and varying capabilities. For many patients, the initial STACH stay is just the beginning of the post-acute care process needed to recover from their illness (Figure 2). This time spent in the post-acute care can be at multiple settings, requiring multiple transitions of care between the STACH, Post-Acute Care Facilities, and in the community setting.

Figure 1.

Long Term Acute Care hospitals (LTACH), Skilled Nursing Facilities (SNFs) chart


Figure 2.

Importance of PAC services differs by condition and patient severity chart


IRFs specialize in intensive rehabilitation care aiming to help patients to function outside of an inpatient environment. LTACHs specialize in the treatment of medically complex patients who require a prolonged length of stay (LOS) of at least 25 days. Both IRFs and LTACHs are classified as acute care hospitals and can be either freestanding or STACH-based facilities. SNFs are not considered hospitals and provide treatment and continuing observation of medically stable patients who require short-term skilled care (e.g. Medicare fully covers 21 days) such as nursing or rehabilitation services in an institutional setting. Nearly 90% of the facilities are free standing, often located in nursing homes. The remainder are located in acute care hospitals and continuing care retirement communities.

Most attention regarding PAC readmissions focuses on SNFs. In 2010, researchers found that nearly 1 in 4 Medicare inpatients were readmitted from SNF 30 days after discharge.1 Medicare tracks hospital readmissions from SNFs for 5 conditions: congestive heart failure, respiratory infections, urinary tract infections, septicemia, and electrolyte imbalance. Unfortunately, the rate for these potentially preventable readmissions has remained steady at 19% from 2000 to 20112 This is in the setting of increased scrutiny by Medicare, focused on increasing PAC spending, especially for SNF care.3

Currently, many STACHs are now partnering with their SNF providers to reduce readmissions due to the Hospital Readmissions Reduction Program (HRRP) mandated by the Patient Protection and Affordable Care Act, and in anticipation of payment reforms promoting across-setting accountability. These partnerships face daunting problems attempting to address the discontinuities created by facility-to-facility transfer of inpatients with multiple medical needs and a potentially substantial decrement in clinical resources, including staff devoted to patient care at SNFs compared to STACHs.

National and Regional Programs Addressing STACH and SNF Transitions:

STAAR Program:

The Institute for Healthcare Improvement (IHI) created a quality initiative program State Action on Avoidable Rehospitalizations (STAAR). The program assists with improving safe transitions on a regional and national level. Having three main sites, Massachusetts, Michigan and Washington the initiative works with patients, families and caretakers to give guidance and support to improve transitions and reduce overall readmissions. STAAR aims cut the cost of readmissions in a two-part strategy. First, engaging participants in collaborative learning process that analyzes best practices and experience based improvements. Then, STAAR uses the new tools and procedures and implements them at a state-level for continuing education and resources.


Intervention to Reduce Acute Care Transfer is a program whose primary goal is to reduce the too frequent readmission of nursing home patients facilitating the implementation of communication tools more effectively.

Quality Improvement Organizations, ICPC:

The Quality Improvement Organizations offer institutions an initiative that will give them access to information and shared knowledge from hospitals, nursing homes, home health agencies, dialysis centers, hospices and palliative care facilities. QIO plans to measure these rates by collecting data from appropriate sites about hospital admissions and readmissions. To ensure the most accurate results, QIO has data collection at a local level as well to improve quality of care.

Minnesota Rare:

RARE, or Reducing Avoidable Readmissions Effectively, is a campaign based in Minnesota that was intended to prevent 4,000 hospital readmissions by December 31, 2012. Minnesota required a statewide effort to achieving their Triple Aim of improving population health, the experience of care, and the affordability of care. Due to their success RARE has furthered the campaign and to date, there have been over 7,000 preventable readmissions.

HIE and RHIOs Examples:

Improving Massachusetts Post-Acute Care Transfers (IMPACT) is designed to improve care transitions for hospitalized patients using an enhanced electronic Universal Transfer Form (UTF) and electronic health information exchange. IMPACT will analyze approximately 100,000 patient transfers in a year. The device will lower avoidable transfers and readmission for nursing home patients, especially.


Keystone Beacon Community has designed a new health information exchange (HIE) making it easier than ever for nurses and other caretakers to share patients’ information with or without an electronic health record. It is important for caretakers to have access to patient’s information recorded from critical long-term and post-acute care facilities to ensure the safest care transitions possible. There is already a tool used to collect data in the Pennsylvania region known as, Keystone Health Information Exchange, or KeyHIE. Doctors from other Pennsylvania hospitals have deemed it necessary to offer more complete assessments.

Nursing Facility Specific Programs:

Electronic Heath Records (EHR):

Although implementation and functional ability of electronic health records in the LTC/SNF is highly variable by facility, most EHRs used in this setting are focused on being able to submit administrative data for CMS payment and quality requirements (e.g. MDS data for SNF prospective payment). However with increasing linkages to STACHs and interest in ACOs, some EHR products are now beginning to incorporate clinical EHR functions, especially for the physician care component.

LTC/SNFs are not included by the Health Information Technology for Economic and Clinical Health (HITECH) Act which incentivizes hospitals and physicians to adopt certified EHRs through the meaningful use program. However, physicians working in the LTC environment are considered ambulatory providers and are subject to the meaningful use rules- unless they have applied for hardship exemptions. Some of EHR vendors are “modularly certified” for certain Office of the National Coordinator for Health Information Technology (ONC) EHR measures and have, for instance, the ability to send a Transitions of Care Summary in compliance with meaningful use stage 2 requirements.

Advancing Excellence:

The Advancing Excellence in America’s Nursing Homes Campaign is a program created by the Advancing Excellence in Long Term Care Collaborative. The aim of this project is to ensure complete quality of care to all nursing home patients.


Optum Palliative and Hospice Care gives patients and families care while facing terminal illness. They are dedicated to assisting and helping patients and families’ lives as comfortable and peaceful as possible. Optum is continuingly recognized for high standards of care from the Community Health Accreditation Program, or CHAP.

Quality Assurance Performance Improvement (CMS):

Quality Assurance/Performance Improvement programs are designed to increase safety and should always involve the analysis of clinical care. After data is collected, it is reevaluated to find best practices and measure goals. Developing and delegating leadership roles to distinguish responsibilities of training and representation of resources are a vital component to making a QAPI program successful. Implementing a feedback system that can record, read and assess all data that has been collected will be essential for comparing best practices to non-best practices and eventually generating Performance Improvement Projects (PIPs). Although, PIPs are used to target a specific clinical situation, or topic and address its dangers and proposing possible ways to overcome the challenges faced. Then, once in completion of all data collecting and reporting, analysis must be made. Also, a plan of action to summarize the problematic areas of many clinical topics faced in hospitals and care settings.

Telemedicine and Nursing Homes

Dr. David C. Grabowski has designed a study analyzing the cause and frequency of nursing home patient hospitalizations. In this study, Dr. Grabowski proposed a new method of diagnosing. Using a two-way video conferencing device, Telemedicine, healthcare providers can consult with patients and families directly, without having to direct them to the ER. Insufficient on-call physician hours often lead to patient hospitalization due to lack of convenience in nursing homes, but implementing Telemedicine may cut costs for hospital transfers and lower readmissions rates. The greatest restriction that comes from this is Medicare compliance. Dr. Grabowski suggests a payment reform and including Telemedicine in Medicare bundling.

LTC trend tracker

The American Health Care Association offers LTC Trend Tracker. The software tracks data to help standardize, and compare in-house reports. The LTC Trend Tracker can also help formulate tendencies and opportunities for institutions and help toward progressing forward.

COMS Interactive

The COMS Daylight IQ is a system designed to aid in team decision making for geriatric patients. COMS Daylight IQ has components such as Disease Management, Automated Clinical Logic/Care Guide, Nursing Assessments and Reporting which all benefit the quality of care for patients, and financial outcomes for the institutions. These functions make it so the system can effectively collaborate with healthcare providers to reduce readmissions and improve overall patients care for nursing home residents.

Leading Age:

This organization is an association of non-for-profit senior services that provide a continuum of care from adult day care to long term care settings. Leading Age has state chapters that  maybe useful in determining resources available to patients transition from hospital to SNF, educational programs, or help with understanding regulatory and advocacy issues that are important to understand when working this transition.

American Health Care Association:

The American Health Care Association (AHCA) is an association of long term and post-acute providers (proprietary and not-for-profit organization) that advocates quality care in these care settings. This organization has a wealth of educational, regulatory, and advocacy information regarding long term and post acute care that maybe helpful to for teams improving transitions from hospitals to the post-acute care setting.

Pharmacy Services:

Pharmacy services for SNFs provided in long term care facilities are often serviced by off-site pharmacies. This may lead to delays in getting specialty medication delivered to the SNF setting for transitioning patients. These pharmacies often provide a consultant pharmacist to review resident/patient medication list to prevent medication adverse events in compliance with LTC regulations. Therefore, acute care providers should not assume that the SNF has its own dedicated 24 hour pharmacy and pharmacy staff to trouble shoot problems with medications that occur on the transfer.


1. Mor V, Intrator O, Feng Z, Grabowski DC. The revolving door of rehospitalization from skilled nursing facilities. Health affairs (Project Hope). Jan-Feb 2010;29(1):57-64.
2. MedPAC. Chapter 8: Skilled Nursing Facility Services. Report to the Congress: Medicare Payment Policy. March, 2013; http://www.medpac.gov/chapters/Mar13_Ch08.pdf.
3. Chandra A, Dalton MA, Holmes J. Large increases in spending on postacute care in Medicare point to the potential for cost savings in these settings. Health affairs (Project Hope). May 2013;32(5):864-872.