Lost in Transition: a Qualitative Study of Patients Discharged from Hospital to Skilled Nursing Facility

Emily A. Gadbois, Denise A. Tyler, Renee Shield, John McHugh, Ulrika Winblad, Joan M. Teno, Vincent Mor

Research output: Contribution to journalArticlepeer-review

22 Scopus citations


Objective: This research aimed to understand the experiences of patients transitioning from hospitals to skilled nursing facilities (SNFs) by eliciting views from patients and hospital and skilled nursing facility staff. Design: We conducted semi-structured interviews with hospital and skilled nursing facility staff and skilled nursing facility patients and their family members in an attempt to understand transitions between hospital and SNF. These interviews focused on all aspects of the discharge planning and nursing facility placement processes including who is involved, how decisions are made, patients’ experiences, hospital-SNF communication, and the presence of programs to improve the transition process. Participants: Participants were 138 staff in 16 hospitals and 25 SNFs in 8 markets across the country, and 98 newly admitted, previously community-dwelling SNF patients and/or their family members in five of those markets. Approach: Interviews were qualitatively analyzed to identify overarching themes. Key Results: Patients reported they felt rushed in making their SNF decisions, did not feel they were appropriately prepared for the hospital-SNF transition or educated about their post-acute needs, and experienced transitions that felt chaotic, with complications they associated with timing and medications. Hospital and SNF staff expressed similar opinions, stating that transitions were rushed, there were problems with the timing of the discharge, with information transfer and medication reconciliation, and that patients were not appropriately prepared for the transition. Staff at some facilities reported programs designed to address these problems, but the efficacy of these programs is unknown. Conclusions: Results indicate problematic transitions stemming from insufficient care coordination and failure to appropriately prepare patients and their family members. Previous research suggests that problematic or hurried transitions from hospital to SNF are associated with medication errors and unnecessary rehospitalizations. Interventions to improve transitions from hospital to SNF that include a focus on patients and families are needed.

Original languageEnglish (US)
Pages (from-to)102-109
Number of pages8
JournalJournal of general internal medicine
Issue number1
StatePublished - Jan 1 2019


  • care transitions
  • communication
  • continuity of care
  • patient-centered care

ASJC Scopus subject areas

  • Internal Medicine


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