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Service Delivery Innovation Profile

Cooperative Network Improves Patient Transitions Between Hospitals and Skilled Nursing Facilities, Reducing Readmissions and Length of Hospital Stays

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Summa Health System created the Care Coordination Network, a cooperative process that strives to ensure smooth transitions between the hospitals and 40 local skilled nursing facilities. The network uses a simplified transfer form, an electronic referral system, regular meetings, and other communication tools to boost the likelihood that each patient is discharged promptly to a facility that can meet his or her medical needs on arrival. The network also works to ensure smooth transitions when patients need to return to a hospital for surgery or testing. The program has led to fewer patients being readmitted to hospitals, lower hospital length of stay for patients transferred to skilled nursing facilities (which, in turn, has increased bed capacity, allowing for 130 additional inpatient admissions each year), and fewer cancellations of tests and surgeries for patients transferred from skilled nursing facilities.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of several metrics related to patients who are transferred between hospitals and SNFs, including readmission rates and average hospital LOS.
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Developing Organizations

Summa Health System
Summit County, OHend dobegin pp

Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

The process of transferring patients between hospitals and skilled nursing facilities (SNFs) is often suboptimal due to communication delays and breakdowns, ineffective documentation, competition between SNFs for patients, and the challenging nature of postacute care patients (who often have multiple illnesses). The net result can be poor medical care for patients and excess costs and capacity constraints for hospitals due to unnecessarily long hospital stays. Common problems that may arise include:
  • Communication delays, leading to prolonged hospital stays, higher costs, and potential capacity constraints: Hospitals often wait until a patient is ready or nearly ready to be discharged before trying to identify a suitable SNF with an available bed. Hospitals usually do not use structured assessments to identify potential transitional care needs at admission. As a result, the patient may spend extra nights in the hospital, which is more expensive than the SNF. These excessive stays drive up hospital costs with no corresponding increase in revenues (because most patients transferred to SNFs are covered by Medicare, which pays a fixed per-case reimbursement) and can also create capacity constraints for hospitals. In fact, Summa found that it had to divert ambulances to other hospitals due to a lack of available inpatient beds more than 30 percent of the time.
  • Inappropriate placements, leading to readmissions: When patients are discharged to a facility that fails to meet their medical needs or is not adequately prepared because of poor communication, the patient may experience complications and require readmission to the hospital. These problems can occur if the facility does not have appropriately trained medical staff (e.g., a physician with expertise in treating a particular disease), the right equipment (e.g., tracheostomy care, beds for bariatric patients), or the patient fails to receive the proper medications (e.g., due to incomplete paperwork). Thirty-day readmission rates commonly range from 15 to 25 percent.1
  • Poor communication for SNF patients returning to hospital: Poor communication may lead to a surgery or a test being canceled for SNF patients as a result of the SNF's failure to ensure that the proper paperwork has been completed (e.g., preoperative information or consents), that the patient is competent to understand the procedure and is accompanied by a legal guardian if necessary, and/or that there is complete contact information for next of kin or the legal guardian.

What They Did

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Description of the Innovative Activity

Summa Health System created the Care Coordination Network to ensure smooth transitions between its hospitals and 37 local SNFs. Major elements of the network include the following:
  • Standardized transfer form: To reduce the chances of miscommunication, participants use a single transfer form that standardizes information. The form includes basic patient information (name, age, diagnosis, medications, allergies) and sections on special care orders (e.g., wound care, the need for restraints), treatment within the last 14 days, pain assessment, the patient's personal possessions, appetite, and other issues. The form also includes a page for physicians to write additional instructions and a checklist that highlights charts and tests that accompany the form (e.g., physical therapy evaluation, nutrition evaluation, living will).
  • Electronic referral process: To identify an appropriate SNF early in the patient's hospital stay, the network uses a software system called the Extended Care Information Network that allows hospitals and SNFs to query one another about bed availability and patient needs. Once a family has narrowed its choice of SNFs to a few facilities, a hospital discharge planner or social worker e-mails patient information to those facilities, allowing SNFs to determine whether they have the resources to meet the patient's specific needs. Each SNF responds to the hospital through the Extended Care Information Network, and the patient/family then makes the final decision with input from the social worker and personal physician.
  • Paperwork policy on surgery/tests: Local ambulance services that transport patients from SNFs to hospitals for surgery or tests also collaborate with the Care Coordination Network by ensuring that patient consent forms and other relevant paperwork is complete and that requirements are met before the patient is transferred. Emergency medical service companies participated in the creation of the transfer forms and policies and provide ongoing feedback of the process.
  • Regular meetings: Network members originally met monthly for approximately 1 year to discuss how the network was working and identify areas for improvement. A steering committee currently meets quarterly, and certain subcommittees meet monthly.
  • Ongoing education and information exchange: Several programs have been developed to ensure that hospital and SNF staff are aware of each other's capabilities:
    • Annual educational fair and period luncheons: The hospitals host an annual educational fair that gives participating SNFs an opportunity to describe their facilities to hospital discharge planners and social workers so that they can make more informed referrals. Each facility has a booth to showcase its features and staff expertise. The hospitals also host occasional luncheons where one or two facilities make presentations to the hospital discharge planners.
    • Tours for hospital staff: The SNFs provide tours of their facilities to hospital officials (including discharge planners and social workers), allowing them to develop a stronger relationship with the SNF staff.
    • Updated manuals: Hospital workers have access to an updated manual describing the SNFs.
    • Hotline for SNFs: SNF staff can call a hotline (staffed by Summa's geriatric coordinator) when they face transition problems.
  • Respiratory management, patient assessment, and reporting protocols: Information provided in August 2011 indicates that the organization continues to work on improving hospital transitional processes. The initiative is led by the Senior Services division and nursing representatives. Protocols guide patient assessment and reporting of the patient's condition to the nursing home attending physician. Respiratory management protocols are used to guide patient care in an attempt to reduce the risk of readmission due to respiratory distress. Clinicians use the SBAR (situation, background, assessment, and recommendations) instrument to guide communication about transitioning patients. Five facilities are piloting the new process and protocols; data collection will end in the third quarter of 2009.
  • Area Agency on Aging case managers embedded in nursing facilities: Information provided in August 2011 indicates that Area Agency on Aging case managers have been successfully integrated into the skilled nursing facilities. This initiative strengthens Summa's attempts to offer patients/consumers additional long-term care options like the Medicaid-waiver community-based long-term care program (i.e., Ohio's PASSPORT program) as well as other community support services for vulnerable older adults. The case managers are notified regarding all extended care and skilled nursing facility discharges. The case managers then provide information and long-term care options to patients/consumers either in the hospital or at the skilled nursing facilities. The goal is to ensure that individuals have knowledge about available community resources and long-term care options during acute hospitalization.
  • Improving Communication for a Community: In 2004, building on the success of the Care Coordination Network's transfer concept, the Akron Regional Hospital Association created a Continuum of Care Committee where 19 membership hospitals (of which Summa is a member) and the extended care community partners worked together to develop one standardized form used for all patient transfers to nursing facilities and long-term acute care hospitals throughout the region. In 2008, this same committee also developed and implemented a standardized extended care-to-hospital transfer form used by all nursing facilities transferring patients to the 19 area hospitals.
  • Ongoing performance measurement and feedback: Summa's quality office collects data on all patients transitioning to and from SNFs. Summa shares blinded, facility-specific performance data with network members every 6 months to identify best practices, target improvement efforts, and recognize outstanding performance. Comparative facility data creates peer pressure that encourages individual SNFs to improve performance, which in turn enhances overall network performance.

Context of the Innovation

Summa Health System, located in Summit County, OH, includes six not-for-profit community and teaching hospitals, four outpatient health centers, a for-profit health plan, and a physician-hospital organization. The hospital system has a total of 2,060 licensed beds and each year admits more than 61,000 inpatients and serves 221,000 emergency department visitors. The creation of the Care Collaboration Network was driven by financial pressure to ensure more timely patient discharges to postacute care without compromising patient care. In particular, reimbursement policies were favoring shorter hospitals stays, and, as noted previously, hospital capacity constraints were causing patients to be diverted to other hospitals. Creating its own SNF was considered but deemed too expensive, so Summa instead chose to partner with local postacute care providers to create the network.

Did It Work?

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The Care Coordination Network has led to fewer SNF patients being readmitted to hospitals, lower hospital length of stay (LOS) for those patients transferred to SNFs (which, in turn, has increased bed capacity, allowing for 130 additional inpatient admissions each year), and fewer cancellations of tests and surgeries for patients transferred from SNFs. Summa is still in the process of testing additional program refinements designed to further reduce LOS and readmissions.
  • Fewer readmissions: Summa's 31-day readmission rate for patients discharged to SNFs dropped from 26 to 24 percent between 2003 (when the program was implemented) and the end of 2006. Information provided in August 2012 indicates a readmission rate of 23.4 percent for the first half of 2011.
  • Shorter stays, leading to increased capacity: Average LOS for the 3,000 patients discharged to SNFs annually fell from 7.4 to 7.1 days between 2003 and the end of 2006. This reduction enabled Summa's hospitals to admit an additional 130 patients annually (without adding staff or resources) and reduce how often they must divert patients to other hospitals because of bed capacity constraints. Information provided in August 2011 indicates that the average LOS has been sustained.
  • Fewer surgery and test cancellations: The number of hospital surgeries and tests canceled due to incomplete paperwork has decreased for patients transferred from SNFs.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of several metrics related to patients who are transferred between hospitals and SNFs, including readmission rates and average hospital LOS.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Preliminary forum: To assess interest in forming a cooperative network, Summa officials invited administrators from 38 local SNFs to attend a forum in 2002. At this session, Summa leaders solicited feedback on the current system, a process that revealed a number of potential opportunities for improvement (e.g., gaps in hospital paperwork that often prevented SNF staff from classifying patients in the appropriate payment categories to receive full reimbursement for required postacute care services).
  • Network formation: After the meeting, 26 SNFs joined with Summa to establish the network (2 more joined 1 year later, and, as of September 2008, the network has 37 members). Summa agreed to provide the space, administrative coordination, and materials for the network. In addition, all members signed a memorandum of agreement accepting the group's mission to improve the quality of care and transitions to and from SNFs.
  • Task force formation: Network leaders created a task force that included representatives from participating SNFs, Summa hospitals, regional emergency medical services, and the local Area Agency on Aging. The task force met biweekly to establish clinical and administrative procedures and quality measures and to begin working on ways to improve transitions. Through the remainder of 2002 and 2003, there were three major phases:
    • Development of a standardized referral process, including guidelines for determining patients' postacute care needs and a quick reference tool for discussing these needs with patients.
    • Identification of priority areas for improving care transitions and creation of a clinical and educational subcommittee to address these areas.
    • Development of outcome measures to monitor member and network performance and establishment of best practice protocols to sustain and encourage quality improvement.
  • Phased implementation and ongoing work: During 2003, the task force gradually implemented new measures for improving transitions. Once the major changes were in place, the task force agreed to reduce the frequency of its meetings to once a month, which later changed to quarterly. Ongoing work is focusing on the implementation of new procedures for transfers from SNFs to emergency departments; these procedures include a new transfer form and a requirement that patients wear wristbands with their names (to eliminate difficulties in identifying patients who are unable to communicate).

Resources Used and Skills Needed

  • Staffing: Network participants did not need to hire additional personnel or engage in special training, because members participate as part of their regular jobs.
  • Costs: The program requires only modest expenses to cover supplies and educational materials.
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Funding Sources

The program is funded through Summa's internal budget and in-kind donations from Summa and the SNFs.end fs

Tools and Other Resources

The transfer form is available at

Adoption Considerations

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Getting Started with This Innovation

  • Solicit feedback from SNF administrators: It is important for hospital officials to treat SNF administrators as valued partners, recognizing that the care provided by SNFs plays a vital role in patient health. They can do so by soliciting and acting on SNF administrators' opinions and ideas for improving transitional care.
  • Build mutual trust: Because SNFs traditionally compete against each other for patients, hospital officials need to show them that cooperating in some areas (e.g., using a standardized form and a shared electronic referral system) will yield benefits, such as producing better matches between patient needs and SNF capabilities (which can lead to fewer readmissions).
  • Be patient and persistent: It can take 6 months or more for SNFs to fully buy in to the network concept.

Sustaining This Innovation

  • Measure performance and provide feedback: Measuring and sharing information on key metrics (e.g., readmission rates, LOS) provides powerful incentives for individual SNFs to improve.
  • Avoid complacency by providing ongoing education and support: Keeping members engaged is a challenge for the network, given the frequent turnover in SNF administrators. The network meets this challenge by holding special events focused on continuous quality improvement and providing ongoing education on the network's vision, guidelines, and performance goals.
  • Attempt to maintain interest and focus of staff in nursing facilities: Maintaining the interest and focus of the staff in nursing facilities is difficult if staff and leadership turnover is significant. The organization should attempt to ensure that new staff are invested and see the value in transitional care.

Spreading This Innovation

The Care Collaboration Network worked with the Akron Regional Hospital Association to disseminate the use of the transfer form to 19 other hospitals.

More Information

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Contact the Innovator

Carolyn Holder, MSN, RN, GCNS-BC
Director, Transitional Care and Utilization Management
Summa Health System
75 Arch Suite G1
Akron, OH 44304
Phone: (330) 375-7784

Kathy Blake
Vice President, Senior Services
Summa Health System
75 Arch Suite G1
Akron, OH 44304

Innovator Disclosures

Ms. Holder and Ms. Blake have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

McCarthy D, Beck C. Summa Health System's Care Coordination Network. Commonwealth Fund Web site. August 29, 2007. Available at:

Ohio hospitals and nursing homes improve care coordination. Perform Improv Advis. 2003;7(10):135-7. [PubMed]


1 Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-8. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: October 27, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 26, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.