​Four factors play a role in making effective care transitions difficult: increasingly complex patient conditions; disparity between real and perceived facility capabilities; financial pressures; and communication barriers. Researchers conducted a survey of 25 hospitals and 16 skilled nursing facilities and identified these common themes among the responses. Their findings are published in the November 2017 issue of The Joint Commission Journal on Quality and Patient Safety. For each of the four themes identified, researchers noted the difference in perspective between hospital care providers and skilled nursing care providers. For example, regarding the increased complexity of patient conditions, hospital providers note that patients are constantly "teetering" on the edge of requiring hospitalization, while skilled nursing care providers perceive that regarding hospital discharge, "people are coming out quicker. They're coming out sicker." Likewise, in selecting the optimal care setting to discharge a patient, hospital providers note that it's "much easier" to discharge a patient to a facility than to home, while skilled nursing providers note that they lack the staff and support that hospitals enjoy. Both provider groups note the complexity in determining what the patient's insurance will cover and how the coverage will affect the care provided. Perhaps most significantly, the researchers highlighted the lack of knowledge providers had regarding one another, as well as the lack of communication regarding the patient's care. "It's almost embarrassing when you have to ask the family what happened in the hospital," notes one skilled nursing respondent. "I just don't have a good understanding of how medical care works at a short-term rehab," admits a hospital care provider. "To positively affect patient care across the continuum, hospitals, [skilled nursing facilities], and research programs must work across institutional silos," write the researchers. "Future interventions should focus on enhancing communication between clinicians, promoting provider understanding of post-acute care, and developing strategic opportunities to align facilities."

HRC Recommends: Safe and effective transitions of care require that the hospital communicate comprehensive information about the patient's history, the care provided at the hospital, and the patient's ongoing needs to the next level of care. Using a standardized form to communicate information to the postacute care provider about a patient's clinical and functional status can reduce the likelihood of miscommunication. Additionally, the hospital must have a good understanding of the postacute care provider's scope of services to prevent a mismatch between the patient's needs and the provider's capabilities.