Why Care Transitions Need to Improve Now

By Pat Twohig | November 8, 2017

Skilled nursing facilities are getting busier. More than 20 percent of all hospitalized older adults who use Medicare will be transitioned and admitted to a SNF following a hospital stay. But patients don’t have a lot of time to decide. A study found most had to choose a skilled nursing facility the day before or even the day of being discharged.¹

Sadly, these numbers don’t surprise me. The climate is changing in healthcare, but case managers and discharge planners need to be able to have accurate data from their post-acute care network in order to arm patients and their family members with this information. Patient choice will always come first when a patient is selecting a facility, but I believe we need patients to be informed.

This is where providers must step up. These three simple actions can help ensure your patients get the information that makes them feel informed and empowered.

1. Ask

Providers should ask their patients as well as their staff their opinions on dining, activities and bathing just to name a few. There are too many patients who feel they’ve had a negative experience when selecting a skilled nursing facility. Patients are suffering the “paradox of choice” where they have too many options. If a facility can ask the right questions, they can arm themselves with the insight they need to give back to the patient and their family.

2. Listen

Providers need to truly listen to their residents and staff and hear what their individual needs are. If Mrs. Smith would prefer to be bathed on Tuesdays rather than Thursdays, what do we have to do to accommodate her?

But also listen to the data.

Data is king! Healthcare systems are trying to support their patients to the best of their ability, but when it comes to choosing a post-acute care setting, many hospitals are still learning how to evaluate a facility. Many skilled nursing facilities across the U.S. do an amazing job focusing on the resident and promoting resident center care practices, but these facilities need to be able to provide the data back to the hospitals to support their programs.

3. Act

Studies show patients are only getting a list of facilities with the names and addresses from discharge planners, and that their team at the hospital wasn’t really involved in the transition. We have to do better than this.

Providers need to act on the information they receive from their residents and staff. The best ideas that most providers share with me, normally stem from a frontline caregiver’s suggestion. These caregivers are the heart and soul of a facility, and can have the greatest impact when trying to create a patient-centered care environment for your resident.

As hospitals are creating more and more preferred skilled nursing networks across the country, they are narrowing their network and requiring these high quality facilities to provide data on key areas so they can share them with their patients prior to discharge. Data, such as the readmission rates along with resident satisfaction information, will help make the process of being discharged to a SNF much more stress-free.

What is your facility doing to make sure patients have the information they need?

We can help you leverage your partnerships with business solutions tailored to improving outcomes and gaining referrals.


1. Hospitalized older adults may need more help selecting skilled nursing facilities. https://www.sciencedaily.com/releases/2017/07/170707211128.htm. July 7, 2017.

Categories: Caregiver Readiness, Expert Views, Healthcare Segment News, Patient Experience

Pat Twohig

Senior Vice President of Post-Acute National Sales

Pat Twohig is the Senior Vice President of Post-Acute National Sales for Medline. Prior to this role, he was the Senior Vice President of Post-Acute National Sales for the Alternate Site Business for Medline that includes long-term care, homecare and the HME marketplace. Twohig began his career with Medline as a sales representative managing the West Virginia market in 2004 and after two years was promoted to manage the Midwest Division.

Twohig graduated from The University of Charleston. In 2013, he received his CEAL Certification (Centerfield Executive for Assisted Living) and is also in the process of receiving his Certificate of Gerontology from Ohio State University. Twohig is a very active participant in several organizations, including the Ohio Person-Centered Care Coalition, Ohio Health Care Association Educational Committee, Health Care of Michigan Education Committee and West Virginia Health Care Association, where he is a legislative member.

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