Hospital readmissions from skilled nursing facilities (SNFs) remain a significant burden to the United States healthcare system, with approximately 20-25% of SNF patients readmitted within 30 days, largely due to modifiable systemic issues. These readmissions are associated with increased healthcare costs, patient morbidity, and fragmented continuity of care, particularly among older adults with complex medical needs. This narrative review synthesizes current evidence to propose a multifaceted framework that targets three core drivers of avoidable readmissions following discharge: communication breakdowns, resource allocation, and inadequate care coordination. A structured literature search was conducted using PubMed/MEDLINE and Google Scholar to identify studies on post-acute care transitions, communication failures, and interventions aimed at reducing readmissions. Established transitional care models, such as INTERACT and Project RED, coupled with emerging programs like TeamHealth’s Post-Acute Care StayPut initiative to ‘treat patients in place’, illustrate how structured workflows, standardized information transfer, and timely escalation pathways can proactively manage clinical decline in SNFs. The proposed framework builds on these models by organizing interventions into scalable tiers based on resource availability and clinical capacity, including telehealth integration, pharmacist-led medication reconciliation, real-time analytics, and enhanced discharge planning. Implementing coordinated, system-wide strategies across care settings is essential to improving continuity of care and reducing avoidable hospital readmissions among vulnerable SNF populations.

Hospital readmissions, Skilled nursing facilities, Transitional care, Care coordination, Post-acute care.

Unplanned hospital readmissions are costly, harmful to patient outcomes, and a prominent quality indicator within the Centers for Medicare and Medicaid Services (CMS) framework. For patients discharged to skilled nursing facilities (SNFs), readmission rates hover between 20-25%, driven by clinical deterioration, communication failures, and insufficient post-discharge planning.[1-5] The hospital readmission reduction program (HRRP), launched by CMS in 2013, penalizes hospitals with excessive readmissions, disproportionately affecting hospitals serving socioeconomically disadvantaged populations.[6-8]

Systemic root causes, including poor transitions of care, delayed responses to patient decline, and under-resourced SNFs, underscore the urgency for reform. This review integrates the aforementioned root causes to propose a unified, multifaceted framework for reducing avoidable hospital readmissions from SNFs. “Avoidable readmissions” refer to hospital transfers that could be reasonably prevented given timely recognition of clinical deterioration, improved communication, and access to appropriate in-facility clinical resources. Through the emphasis of treat-in-place models and real-time escalation pathways, the paper aims to bridge the gap between transitional care theory and implementation in post-acute care settings.

To address these gaps, we propose a tiered, system-level framework for reducing avoidable hospital readmissions from SNFs. The framework integrates communication, resource allocation, and care coordination to organize interventions based on the level of resource availability and feasibility of implementation. Currently, existing models primarily focus on specific tools or workflows, often without fully integrating them into a scalable, system-level approach.

This narrative review was conducted to synthesize current evidence on avoidable hospital readmissions from SNFs and to inform the development of a systems-level framework targeting key drivers of readmissions. A structured literature search was performed using PubMed/MEDLINE and Google Scholar to identify relevant studies on post-acute care transitions, communication failures, care coordination, and interventions aimed at reducing hospital readmissions. Search was focused on articles published within the past 10-15 years to ensure relevance to contemporary clinical practice and healthcare policy.

Search terms included combinations of keywords such as “skilled nursing facility readmissions,” “post-acute care transitions,” “care coordination,” “transitional care,” “INTERACT,” “Project RED,” and “telehealth in skilled nursing facilities.” Boolean operators (AND/OR) were used to refine search results and capture studies addressing both clinical and systems-level interventions.

Studies included if they (1) involved adult populations in post-acute or skilled nursing facility settings, (2) evaluated interventions or contributing factors related to hospital readmissions, and (3) reported clinically relevant outcomes such as readmission rates, care transitions, or management of clinical deterioration. Eligible study designs included randomized controlled trials, observational studies, qualitative analyses, and prior systematic reviews.

Studies were excluded if they focused on pediatric populations, lacked relevance to post-acute care settings, or did not include measurable or descriptive outcomes related to readmissions or care transitions. Editorials, opinion pieces, and case reports were excluded unless they provided foundational context for widely adopted care models.

Titles and abstracts were initially screened for relevance, followed by a full-text review of selected articles to confirm eligibility. Additional relevant studies were identified through manual review of reference lists from key publications. Given the conceptual and framework-building nature of this review, formal meta-analysis and quantitative synthesis were not performed.

Included studies were qualitatively assessed for methodological rigor, relevance to SNF-based care delivery, and applicability to system-level interventions. Findings were synthesized thematically to identify recurring drivers of readmissions, specifically communication breakdowns, resource limitations, and care coordination gaps, which informed the development of a tiered, systems-level framework.

Transitional challenges in post-acute care: The transition from hospital to SNF is characterized by multiple vulnerabilities. Discharge packets often omit critical information such as pending diagnostics, reconciled medications, or follow-up plans. Studies report that over one-third of SNFs receive incomplete discharge summaries.[9,10] The aforementioned lapses jeopardize early decision-making and delay critical interventions, especially within the first 48-72 hours post-discharge, a known high-risk window.[11,12]

Further compounding the transitional challenges from hospitals to SNFs are inadequate staffing, poor electronic health record (HER) interoperability, and inconsistent use of health information exchanges (HIEs).[13-16] SNFs are often forced into reactive care models, escalating to emergency transfers instead of managing patients in-house. Telehealth adoption and protocols like INTERACT and Project RED have shown promise in bridging communication and clinical intervention gaps, but their application remains inconsistent.[3,17,18] INTERACT and Project RED have set frameworks for hospitals and SNFs to improve interfacility communication and patient education while providing SNFs with the clinical advantage to identify clinical deterioration and proactively prepare and communicate care plans with providers.[19-21]

Communication failures and clinical impact: Building on these systemic gaps, communication failures at the point of care directly contribute to delayed recognition and management of clinical deterioration in SNF patients.[10] Yet SNF staff often receive late, incomplete, or clinically insufficient handoffs.[1,13,22,23] Studies have found that poor transitional documentation directly contributes to delays in treatment and higher readmission rates.

Verbal reports from discharging clinicians to nursing facilities without standardized protocols result in missing elements such as goals of care or escalation plans.[15,16] Missing discharge information is particularly dangerous for geriatric patients with multiple comorbidities, where rapid clinical changes are common.[10,11] Programs like INTERACT and Project RED emphasize early recognition and proactive response but require committed integration into SNF workflows for sustained success.[11]

Clinical deterioration in SNFs often stems from predictable conditions like heart failure, COPD, pneumonia, and sepsis.[24-27] Despite this predictability, SNFs frequently lack clinical infrastructure to intervene. Early-warning systems and adequately trained staff are not universally available within SNFs, leading to delayed recognition or hesitation in escalating care.[1,24,28,17]

Rockwell et al., observed that liability concerns and lack of escalation protocols led staff to default to hospital transfers.[24] Chess et al. emphasized the value of telemedicine during clinician off-hours to reduce unnecessary transfers.[17] These findings point to the need for defined escalation pathways, 24/7 clinician access, and enhanced facility staff training to manage patients on-site.

Interventions: Building clinical capacity and coordination: The proposed framework organizes interventions into a tiered structure, reflecting the need for increased levels of clinical capacity, resource availability, and system integration. These tiers are not rigid but instead provide a scalable pathway for facilities to enhance their ability to prevent avoidable hospital transfers. Multidisciplinary teams comprised of physicians, advanced practice clinicians (APCs), registered nurses (RNs), and pharmacists are vital in managing high-acuity SNF patients. Pharmacist-led medication reconciliation reduces risks associated with polypharmacy common in geriatric populations.[29-32] Working alongside pharmacists, physicians, APCs, and RNs collaborate to detect patient deterioration, enabling them to intervene, promoting safer care transitions, and improving outcomes for geriatric patients in post-acute settings.[11,17,18,25]

Programs like INTERACT and Project RED offer assessment tools and standardized communication workflows to identify and address clinical deterioration early.[33] When consistently implemented, such models reduce 30-day readmissions and foster trust between hospitals and SNFs.[18,20,34,35]

StayPut, a clinical excellence program developed by TeamHealth Post-Acute Care medical practice, operationalizes structured assessments through root cause analysis within SNFs to enable early intervention and reduce avoidable hospital transfers. By embedding structured and systemic changes within overnight workflows, clinicians can assess, treat, and stabilize patients in place while coordinating appropriate follow-up through the electronic medical record.

Real-time data analytics represent an emerging frontier in SNF readmission reduction. Predictive tools, such as Early Warning Scores, enable risk stratification during the crucial post-discharge period. Facilities using telehealth and real-time monitoring have shown improved responsiveness to acute changes.[17,26,28,36-38]

Integration of EHR systems across hospital and SNF settings remains limited, but platforms that support consistent, bidirectional communication are essential. These systems enable SNFs to access lab results, diagnostic tests, and medication changes without delay, ensuring clinical actions align with the discharge plan.[18,33,39] While established models such as INTERACT and Project RED provide structured tools to improve communication and early recognition of clinical deterioration, they primarily function at the workflow level. In contrast, the proposed framework integrates these tools within a broader systems-level approach, emphasizing scalability, resource stratification, and cross-setting coordination. This distinction allows for more flexible implementation across diverse SNF environments (Table 1).

While TeamHealth’s StayPut program demonstrates the potential of treat-in-place models, their scalability depends on facility workforce availability and leadership support and financial alignment. Facilities with limited staffing or access to on-call clinicians may face barriers to adoption, underscoring the need for tiered implementation strategies.

Table 1: Tiered systems-level framework for reducing skilled nursing facility readmissions

Challenges and gaps in implementation: Despite the availability of evidence-based transitional care and readmission-reduction frameworks, including INTERACT and Project RED, implementation across SNFs remains inconsistent. SNFs, in under-resourced or rural settings, lack the financial and staffing capacity to adopt comprehensive interventions.[1,2,12,40,41] The HRRP, while aimed at incentivizing quality, often exacerbates disparities by penalizing the very institutions with the least resources.[6,42-44]

Moreover, current interventions are often pilot-based or grant-funded, with limited sustainability. Programs like INTERACT, Project RED, and StayPut, while effective, must be embedded into routine operations with leadership buy-in, ongoing staff training, and financial support to ensure long-term adoption.[19,21,45,46]

A tiered approach to implementation may be necessary to ensure feasibility due to the diverse nature of skilled nursing facilities. At a minimum, facilities may adopt standardized discharge communication tools from the referring hospitals, clear escalation protocols, and structured after-hours clinician access through telehealth-supported coverage.[37] Facilities able to carry greater clinical capacity may integrate pharmacist-led medication reconciliation, use of early warning scores, and scheduled case reviews during post-discharge periods. Advanced models of the tiered approach may incorporate real-time predictive analytics, embedded rapid-response teams, and formalized treat-in-place pathways. The StayPut program exemplifies this higher-tier approach by formalizing treat-in-place pathways within SNFs to reduce avoidable hospital transfers. The proposed tiered, systems-level framework provides a practical and scalable approach for addressing avoidable readmissions in SNFs by aligning interventions with available resources and clinical capacity. By integrating communication, care coordination, and clinical infrastructure into a unified model, this framework moves beyond isolated interventions toward sustainable, system-wide improvement in post-acute care delivery.

Limitations: As a narrative review, it does not employ a formal systematic methodology or quantitative synthesis, which may introduce selection bias. Additionally, variability in study design and implementation across SNF settings may limit the generalizability of certain interventions.

Reducing avoidable hospital readmissions from SNFs requires a holistic approach. Strengthening transitional communication, enhancing clinical competency, and integrating data-driven tools are essential components of this strategy. Programs like TeamHealth’s StayPut demonstrate that structured, interdisciplinary, and proactive care can reduce readmissions and restore trust in post-acute care.

Policymakers, hospital systems, and SNFs must align efforts to invest in technology, training, and standardized processes that support seamless transitions and ensure consistent, on-demand clinical care, including the use of telehealth when in-person resources are limited. Only through systemic reform beyond punitive reimbursement models can the healthcare system reduce readmissions and deliver dignified, high-quality care to vulnerable populations. Future work should focus on evaluating how these models can be sustainably implemented across diverse SNF settings and supported by reimbursement structures that incentivize in-place care rather than reactive hospitalization.

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Corresponding Author:
Arshdeep Sandhu
Department of Biomedical Science
Tufts School of Medicine, US
Email: [email protected]

Co-Authors:
Jonathan Raffesberger, Najla Bryant, Darren Swenson
Department of Post-Acute Care
TeamHealth, US

Arshdeep Sandhu conceptualized the study, conducted the literature review, and drafted the manuscript. Jonathan Raffesberger, Najla Bryant, and Darren Swenson contributed to manuscript revision, critical feedback, and final approval of the version to be published.

Not applicable

The authors declare no conflicts of interest.

Arshdeep Sandhu is the guarantor of this study and takes full responsibility for the integrity of the data and the accuracy of data analysis.

https://doi.org/10.63096/medtigo3062425

Sandhu A, Raffesberger J, Bryant N, Swenson D. Avoidable Post-Acute Care Readmissions: A Tiered Systems-Level Framework for Communication, Coordination, and Clinical Capacity. medtigo J Med. 2026;4(2):e3062425. doi:10.63096/medtigo3062425 Crossref