The Skilled Nursing Facility (SNF) Alliance achieved significant progress in FY26, exceeding targets and building participant trust. This year-end summary highlights how the Alliance continued to strengthen collaboration among hospitals, skilled nursing facilities, and community partners to support safer, smoother transitions for patients moving from hospital care into skilled nursing settings. It also offers a preview of what is in store for the year ahead, including continued efforts to improve coordination among partners, reduce avoidable readmissions, and better support patients and families during a vulnerable point in recovery.
FY26 Progress Shows Measurable Impact
In FY26, the SNF Alliance advanced a data-driven approach to quality improvement, using ongoing monitoring of readmissions, admissions and discharges, infection trends, vaccination rates, and other quality measures to identify opportunities for action. That focus produced meaningful results across priority areas:
This collaboration “brings hospital and community partners together to help connect people with the care and support they need, with the goal of reducing unnecessary hospital visits and improving health in our community,” one SNF participant said. “Proud to be a part of it.”
Looking Ahead: FY27 Priorities
Building on that momentum, the Alliance is entering FY27 by pulling together three priority workgroups designed to address some of the most pressing challenges in post-acute care: complex care transitions and patient handoffs, congestive heart failure, and sepsis prevention.
Complex Care Transitions and Patient Handoffs
The Complex Care Transitions workgroup will focus on standardizing patient handoffs, strengthening hospital-SNF collaboration, defining and tracking medically complex patients, and improving engagement with patients and families. Its phased implementation plan will move from definition to implementation, evaluation, and sustainability.
Earlier and better-coordinated transfers remain a key part of this work. Meeting the HSCRC discharge-before-11:00 a.m. metric continues to be a priority because timely transfers can improve patient experience, support medication access, and help skilled nursing facilities prepare for admissions more effectively.
Congestive Heart Failure
The CHF workgroup will review current hospital-based CHF initiatives, conduct a gap analysis, and identify opportunities to better align hospital and SNF approaches. The goal is to support more consistent care for patients with congestive heart failure as they move across settings.
Sepsis Prevention
The Sepsis Prevention workgroup will take an organism-specific approach, supported by monthly infection trend reporting and collaboration with the Maryland Department of Health Infection Prevention and Control Team. By tailoring interventions to gram-positive and gram-negative organism trends, the Alliance aims to support more targeted infection prevention strategies.
Collaboration Remains the Foundation
The SNF Alliance endures because it identifies the problems that are best solved together. For example, Alliance members discussed transportation as a practical barrier to meeting discharge goals that can affect both patient outcomes and operational efficiency. Transportation delays and late-day discharges can slow patient flow, extend hospital stays, and make it harder for skilled nursing facilities to complete admissions smoothly. Participants highlighted the value of sharing successful transportation models, including wheelchair-accessible options, and encouraged broader collaboration across SNFs to reduce discharge delays, improve bed availability, and support system-wide performance goals.
As the SNF Alliance moves into FY27, its work reflects PCC’s broader commitment to building partnerships and strengthening systems that improve health. By bringing care teams together around shared data, common goals, and practical solutions, the Alliance is helping create safer transitions and better outcomes for patients across the region.
FY26 Progress Shows Measurable Impact
In FY26, the SNF Alliance advanced a data-driven approach to quality improvement, using ongoing monitoring of readmissions, admissions and discharges, infection trends, vaccination rates, and other quality measures to identify opportunities for action. That focus produced meaningful results across priority areas:
- The Alliance exceeded its C. diff goal by 58.5% and its UTI goal by 17.5%.
- All five quality improvement facilities improved readmission performance, resulting in 68 avoided readmissions.
- The SNF Alliance received CDC certification in hand hygiene, environmental cleaning and disinfection, and personal protective equipment.
- Prevented readmissions generated an estimated $560,000 in hospital savings.
This collaboration “brings hospital and community partners together to help connect people with the care and support they need, with the goal of reducing unnecessary hospital visits and improving health in our community,” one SNF participant said. “Proud to be a part of it.”
Looking Ahead: FY27 Priorities
Building on that momentum, the Alliance is entering FY27 by pulling together three priority workgroups designed to address some of the most pressing challenges in post-acute care: complex care transitions and patient handoffs, congestive heart failure, and sepsis prevention.
Complex Care Transitions and Patient Handoffs
The Complex Care Transitions workgroup will focus on standardizing patient handoffs, strengthening hospital-SNF collaboration, defining and tracking medically complex patients, and improving engagement with patients and families. Its phased implementation plan will move from definition to implementation, evaluation, and sustainability.
Earlier and better-coordinated transfers remain a key part of this work. Meeting the HSCRC discharge-before-11:00 a.m. metric continues to be a priority because timely transfers can improve patient experience, support medication access, and help skilled nursing facilities prepare for admissions more effectively.
Congestive Heart Failure
The CHF workgroup will review current hospital-based CHF initiatives, conduct a gap analysis, and identify opportunities to better align hospital and SNF approaches. The goal is to support more consistent care for patients with congestive heart failure as they move across settings.
Sepsis Prevention
The Sepsis Prevention workgroup will take an organism-specific approach, supported by monthly infection trend reporting and collaboration with the Maryland Department of Health Infection Prevention and Control Team. By tailoring interventions to gram-positive and gram-negative organism trends, the Alliance aims to support more targeted infection prevention strategies.
Collaboration Remains the Foundation
The SNF Alliance endures because it identifies the problems that are best solved together. For example, Alliance members discussed transportation as a practical barrier to meeting discharge goals that can affect both patient outcomes and operational efficiency. Transportation delays and late-day discharges can slow patient flow, extend hospital stays, and make it harder for skilled nursing facilities to complete admissions smoothly. Participants highlighted the value of sharing successful transportation models, including wheelchair-accessible options, and encouraged broader collaboration across SNFs to reduce discharge delays, improve bed availability, and support system-wide performance goals.
As the SNF Alliance moves into FY27, its work reflects PCC’s broader commitment to building partnerships and strengthening systems that improve health. By bringing care teams together around shared data, common goals, and practical solutions, the Alliance is helping create safer transitions and better outcomes for patients across the region.
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