The transition between hospital to skilled nursing facility presents a key opportunity to reduce hospitalization risk, improve outcomes and save money — but a new study finds that players on both sides often aren’t on the same page. The research team, led by SarwatChaudhry of the Yale Center for Healthcare Innovation, Redesign, and Learning (CHIRAL), identified four major problems that arise during the handoff from hospital to SNF: increasing patient acuity, financial pressures, communication breakdowns and difficulty identifying strong referral partners. “At times, hospital and SNF providers seemed pitted against one another, as each institution remained primarily focused on addressing its own fiscal and performance metrics, with less consideration of the effectiveness or cost of the overall plan of care,” the authors wrote. The study, featured in the November issue of The Joint Commission Journal on Quality and Patient Safety, incorporates candid interviews with employees at one hospital and two local SNFs in the Northeast — including an urban, non-profit nursing home and a for-profit, suburban SNF. The skilled facilities were among the hospital’s top 10 discharge sites by volume, and all study participants had direct experience with hospital-to-SNF transitions. The responses were frank. One SNF employee told the researchers that hospitals often overpromised the outcomes that patients would achieve, a particularly concerning trend considering the growing ranks of SNF residents with complex medical issues. “They’re sending them here with the assumption: ‘You’re gonna get rehab. In a couple of weeks, you’re gonna get stronger and you’re gonna go home,’” the SNF worker said. “That...