University of Massachusetts Medical School Faculty Publications


A Pilot Health Information Technology-Based Effort to Increase the Quality of Transitions From Skilled Nursing Facility to Home: Compelling Evidence of High Rate of Adverse Outcomes

UMMS Affiliation

Meyers Primary Care Institute; Department of Medicine, Division of Geriatric Medicine; Department of Quantitative Health Sciences

Publication Date


Document Type



Geriatrics | Health Information Technology | Health Services Administration


OBJECTIVES: Older adults are often transferred from hospitals to skilled nursing facilities (SNFs) for post-acute care. Patients may be at risk for adverse outcomes after SNF discharges, but little research has focused on this period.

DESIGN: Assessment of the feasibility of a transitional care intervention based on a combination of manual information transmission and health information technology to provide automated alert messages to primary care physicians and staff; pre-post analysis to assess potential impact.

SETTING: A multispecialty group practice.

PARTICIPANTS: Adults aged 65 and older, discharged from SNFs to home; comparison group drawn from SNF discharges during the previous 1.5 years, matched on facility, patient age, and sex.

MEASUREMENTS: For the pre-post analysis, we tracked rehospitalization within 30 days after discharge and adverse drug events within 45 days.

RESULTS: The intervention was developed and implemented with manual transmission of information between 8 SNFs and the group practice followed by entry into the electronic health record. The process required a 5-day delay during which a large portion of the adverse events occurred. Over a 1-year period, automated alert messages were delivered to physicians and staff for the 313 eligible patients discharged from the 8 SNFs to home. We compared outcomes to those of individually matched discharges from the previous 1.5 years and found similar percentages with 30-day rehospitalizations (31% vs 30%, adjusted HR 1.06, 95% CI 0.80-1.4). Within the adverse drug event (ADE) study, 30% of the discharges during the intervention period and 30% of matched discharges had ADEs within 45 days.

CONCLUSION: Older adults discharged from SNFs are at high risk of adverse outcomes immediately following discharge. Simply providing alerts to outpatient physicians, especially if delivered multiple days after discharge, is unlikely to have any impact on reducing these rates.


UMCCTS funding, Ambulatory care, health information technology, medication safety, skilled nursing facilities

DOI of Published Version



J Am Med Dir Assoc. 2016 Apr 1;17(4):312-7. doi: 10.1016/j.jamda.2015.11.008. Epub 2015 Dec 23. Link to article on publisher's site

Related Resources

Link to Article in PubMed

Journal/Book/Conference Title

Journal of the American Medical Directors Association

PubMed ID