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Decreasing Readmissions Through Transitional Care from Skilled Nursing Facilities to Home

      Hospitals and skilled nursing facilities (SNF) face growing financial pressure to decrease readmission rates. Transitional care has proven effective for patients with chronic conditions across healthcare settings, typically from the hospital to home or from the hospital to SNF. However, it is rarely implemented when transitioning a patient from SNF to home. Many of these patients are placed in SNF after hospital discharge because of significant co-morbid conditions that place them at high risk for readmission, and many of the factors causing the risk are still present at discharge from SNF.
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