How Context Influences Hospital Readmissions from Skilled Nursing Facilities: A Rapid Ethnographic Study

Roman Ayele, Kirstin A. Manges, Chelsea Leonard, Marcie Lee, Emily Galenbeck, Mithu Molla, Cari Levy, Robert E. Burke

    Research output: Contribution to journalArticlepeer-review

    1 Scopus citations


    Introduction: Improving hospital discharge processes and reducing adverse outcomes after hospital discharge to skilled nursing facilities (SNFs) are gaining national recognition. However, little is known about how the social-contextual factors of hospitals and their affiliated SNFs may influence the discharge process and drive variations in patient outcomes. We sought to categorize contextual drivers that vary between high- and low-performing hospitals in older adult transition from hospitals to SNFs. Design: To identify contextual drivers, we used a rapid ethnographic approach with interviews and direct observations of hospital and SNF clinicians involved in discharging patients. We conducted thematic analysis to categorize contextual factors and compare differences in high- and low-performing sites. Setting and Participants: We stratified hospitals on 30-day hospital readmission rates from SNFs and used convenience sampling to identify high- and low-performing sites and associated SNFs. The final sample included 4 hospitals (n = 2 high performing, n = 2 low performing) and affiliated SNFs (n = 5) with 148 hours of observations. Measures: Central themes related to how contextual factors influence variations in high- and low-performing hospitals. Results: We identified 3 main contextual factors that differed across high- and low-performing hospitals and SNFs: team dynamics, patient characteristics, and organizational context. First, we observed high-quality communication, situational awareness, and shared mental models among team members in high-performing sites. Second, the types of patients cared for at high-performing hospitals had better insurance coverage that made it feasible for clinicians to place patients based on their needs instead of financial abilities. Third, at high-performing hospitals a more engaged staff in the transition process and building rapport with SNFs characterized smooth transitions from hospitals to SNFs. Conclusions and Implications: Contextual factors distinguish high- and low-performing hospitals in transitions to SNF and can be used to develop interventions to reduce adverse outcomes in transitions.

    Original languageEnglish (US)
    JournalJournal of the American Medical Directors Association
    StateAccepted/In press - 2020


    • Context of care
    • older adults
    • transitions of care

    ASJC Scopus subject areas

    • Nursing(all)
    • Health Policy
    • Geriatrics and Gerontology


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