The document provided is a detailed exploration and emphasis on the importance of efficient processes for transferring patients between nursing facilities and acute-care hospitals and vice versa, with the inclusion of the emergency department.

The highlighted areas are included in this document:

  • Patient-Centered Care (Culture Change)
  • Medication Reconciliation
  • Information Transfer
  • Medical Director Oversight
  • Transfer of Information from the ACH to the SNF/NF
  • Electronic Health Records and HIPAA
  • Medications
  • SNF/NF Readmissions Versus New Admissions
  • Improving Communication Between the ACH and SNF/NF
  • Patient/Family Education and Involvement
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Improving Care Transitions Between the Nursing Facility and the Acute-Care Hospital Settings




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