Transitions of Care from SNF to Home

One in four ACO patients that transitioned to a skilled nursing facility from Mount Sinai Health System returned to the hospital within 30 days. Recognizing that this was an issue for both patients and providers, the team at Mount Sinai helped their SNF partners put into place discharge planning practices – like medication reconciliation, follow-up PCP appointments, SDOH and community resources – to give patients the resources they needed for a successful discharge.

Download this webinar to hear from the Mount Sinai team as they discuss the program, how they worked with their SNF providers and the positive outcomes and lessons learned.