The Skilled Nursing Facility (SNF) Alliance continues to be a cornerstone of collaborative care across our region, bringing hospitals, skilled nursing facilities, and community partners together around one shared goal: better outcomes for patients transitioning between care settings.
At its core, the SNF Alliance is focused on strengthening communication, coordination, and accountability between care teams. These efforts are especially critical for patients who are at higher risk for complications, readmissions, or setbacks during recovery. By improving how they share information and align care plans across settings, the Alliance aims to reduce avoidable readmissions, prevent errors, and support smoother, safer transitions for patients and families. “When everyone is on the same page—from the hospital to the SNF—the difference for patients is immediate. The Alliance helps us support safer transitions and better outcomes when patients need it most,” points out Juhi Morrison, PCC Clinical Director, Programs.
What Good Care Transitions Look Like
Through the Alliance, SNFs and hospital partners have identified several practices that make care transitions more effective. These include ensuring accurate and timely transfer of clinical information, establishing clear and actionable care plans, and holding brief touchpoint meetings between hospital and SNF representatives prior to a patient’s transfer. Whenever possible, these conversations also include patients and families, helping ensure everyone understands the plan of care and what to expect next. Equally important is a shared understanding of the specialties, services, and capabilities available across our SNF partners. “By helping hospital and SNF teams connect early and share clear, consistent information, PCC plays a key role in keeping care transitions coordinated. That alignment helps patients and families feel supported and allows care teams to focus on a smoother, safer transition,” Morrison notes.
New Area of Focus: Care Transitions and Complex Patient Handoffs
This year, the SNF Alliance has named care transitions and complex patient handoffs as a dedicated workgroup area of focus. (A “care handoff” refers to the transfer of responsibility for a patient from one care team to another—such as from a hospital team to a skilled nursing facility.) When these handoffs are complex, involving multiple conditions, medications, or social needs, the risk for miscommunication increases. Because this is a newly selected focus area, Alliance members are actively working together to define clear goals, determine how progress will be measured, and establish a shared vision of what success looks like. This collaborative approach ensures that improvements are meaningful, measurable, and grounded in the real-world experiences of care teams across settings.
At its core, the SNF Alliance is focused on strengthening communication, coordination, and accountability between care teams. These efforts are especially critical for patients who are at higher risk for complications, readmissions, or setbacks during recovery. By improving how they share information and align care plans across settings, the Alliance aims to reduce avoidable readmissions, prevent errors, and support smoother, safer transitions for patients and families. “When everyone is on the same page—from the hospital to the SNF—the difference for patients is immediate. The Alliance helps us support safer transitions and better outcomes when patients need it most,” points out Juhi Morrison, PCC Clinical Director, Programs.
What Good Care Transitions Look Like
Through the Alliance, SNFs and hospital partners have identified several practices that make care transitions more effective. These include ensuring accurate and timely transfer of clinical information, establishing clear and actionable care plans, and holding brief touchpoint meetings between hospital and SNF representatives prior to a patient’s transfer. Whenever possible, these conversations also include patients and families, helping ensure everyone understands the plan of care and what to expect next. Equally important is a shared understanding of the specialties, services, and capabilities available across our SNF partners. “By helping hospital and SNF teams connect early and share clear, consistent information, PCC plays a key role in keeping care transitions coordinated. That alignment helps patients and families feel supported and allows care teams to focus on a smoother, safer transition,” Morrison notes.
New Area of Focus: Care Transitions and Complex Patient Handoffs
This year, the SNF Alliance has named care transitions and complex patient handoffs as a dedicated workgroup area of focus. (A “care handoff” refers to the transfer of responsibility for a patient from one care team to another—such as from a hospital team to a skilled nursing facility.) When these handoffs are complex, involving multiple conditions, medications, or social needs, the risk for miscommunication increases. Because this is a newly selected focus area, Alliance members are actively working together to define clear goals, determine how progress will be measured, and establish a shared vision of what success looks like. This collaborative approach ensures that improvements are meaningful, measurable, and grounded in the real-world experiences of care teams across settings.
“When everyone is on the same page—from the hospital to the SNF—the difference for patients is immediate. The Alliance helps us support safer transitions and better outcomes when patients need it most.”
Demonstrated Results and Ongoing Value
The SNF Alliance’s longevity reflects its ability to deliver real value. Recent successes include meaningful reductions in Clostridioides difficile (C. diff) infections—an outcome that speaks directly to improved care practices, coordination, and infection prevention efforts across partner organizations.
The Alliance also continues to demonstrate value for all stakeholders:
The SNF Alliance’s longevity reflects its ability to deliver real value. Recent successes include meaningful reductions in Clostridioides difficile (C. diff) infections—an outcome that speaks directly to improved care practices, coordination, and infection prevention efforts across partner organizations.
The Alliance also continues to demonstrate value for all stakeholders:
- Hospitals benefit through improved return on investment (ROI), driven by fewer readmissions and better care coordination.
- Skilled Nursing Facilities see improvements in quality metrics, including star ratings, strengthening their ability to serve patients and partner effectively with hospitals. In fact, 19 facilities are 5-star for quality and 12 facilities have improved their star rating.
- There was a 73% reduction in C.Diff rates for the 10 lowest-performing facilities who were a part of the workgroup. There was a 75% reduction in C. Diff rates for the remainder of the SNF Alliance.
- Patients experience smoother transitions, fewer disruptive returns to the hospital, and greater support during recovery.
Expanding Beyond Hospitals and SNFs
In addition to hospital and SNF collaboration, the Alliance actively engages community stakeholders to broaden the support available to patients. These partnerships enhance both clinical and operational efforts, helping address social needs, streamline processes, and strengthen the overall safety net for our community. “By partnering with community organizations, we’re able to support patients beyond the walls of our facilities. These relationships help us address social needs, reduce barriers to care, and ensure patients have the support they need for a safer, more successful recovery,” sums up Morrison.
As care continues to grow more complex, the Skilled Nursing Facility Alliance remains a powerful example of what can be achieved through shared accountability, open communication, and a commitment to continuous improvement. Together, we are building a more connected system of care—one transition at a time.
In addition to hospital and SNF collaboration, the Alliance actively engages community stakeholders to broaden the support available to patients. These partnerships enhance both clinical and operational efforts, helping address social needs, streamline processes, and strengthen the overall safety net for our community. “By partnering with community organizations, we’re able to support patients beyond the walls of our facilities. These relationships help us address social needs, reduce barriers to care, and ensure patients have the support they need for a safer, more successful recovery,” sums up Morrison.
As care continues to grow more complex, the Skilled Nursing Facility Alliance remains a powerful example of what can be achieved through shared accountability, open communication, and a commitment to continuous improvement. Together, we are building a more connected system of care—one transition at a time.
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