Purpose: The purpose of this white paper is to recognize and emphasize the importance of efficient patient-centered processes for transferring patients from the acute-care hospital (ACH) to skilled nursing facility/nursing facility (SNF/NF) and from SNF/NF to ACH, including the emergency department (ED). Rather than duplicate the practical material already available in PALTmed’s recently published Clinical Practice Guidelines (CPG) Transitions of Care in the Long-Term Care Continuum and Acute Change of Condition in the Long-Term Care Setting, documents and tools from the National Transitions of Care Coalition (NTOCC), and others, this paper aims to highlight critical factors in the care transition process and to specify key features of a successful care transition process. We will refer to some specific documents and tools currently available, but these are by no means exhaustive, and the interested reader is directed to the additional resources found in the Summary of Available Tools section.
Note: Effective August 13, 2024, AMDA - The Society for Post-Acute and Long-Term Care Medicine is now Post-Acute and Long-Term Care Medical Association (PALTmed).