Journal of General Internal Medicine

, Volume 34, Issue 1, pp 102–109 | Cite as

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

  • Emily A. GadboisEmail author
  • Denise A. Tyler
  • Renee Shield
  • John McHugh
  • Ulrika Winblad
  • Joan M. Teno
  • Vincent Mor
Original Research



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.


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 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.


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.


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.


care transitions communication continuity of care patient-centered care 



NIA P01 AG027296

Commonwealth Fund 20150004

Compliance with Ethical Standards

Participants signed a consent form that was approved by our university’s Institutional Review Board.

Conflict of Interest

John McHugh holds a consultancy with Navigant Consulting, Inc. Vincent Mor holds a consultancy with NaviHealth, Inc., holds equity with PointRight, Inc., and is the paid Chair of the Independent Quality Committee at HCR Manorcare. All the remaining authors declare that they do not have a conflict of interest.

Supplementary material

11606_2018_4695_MOESM1_ESM.docx (35 kb)
ESM 1 (DOCX 34.5 kb)


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Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Emily A. Gadbois
    • 1
    Email author
  • Denise A. Tyler
    • 2
  • Renee Shield
    • 1
  • John McHugh
    • 3
  • Ulrika Winblad
    • 4
  • Joan M. Teno
    • 5
  • Vincent Mor
    • 1
  1. 1.Center for Gerontology and Healthcare Research Brown University School of Public HealthProvidenceUSA
  2. 2.RTI InternationalResearch Triangle ParkUSA
  3. 3.Mailman School of Public HealthColumbia UniversityNew YorkUSA
  4. 4.Department of Public Health and Caring SciencesUppsala UniversityUppsalaSweden
  5. 5.Division of General Internal Medicine & GeriatricsOregon Health Sciences UniversityPortlandUSA

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