New National Study Finds Large Gaps in Information Sharing between Hospitals and Skilled Nursing Facilities


San Francisco, CA. For the millions of older adults who transition from hospitals to skilled nursing facilities (SNFs) each year, the continuity of their care depends on how well hospitals and SNFs share key information about their health and healthcare.  Today, researchers from the Center for Clinical Informatics and Improvement Research (CLIIR) at the University of California San Francisco (UCSF), Harvard T.H. Chan School of Public Health, Massachusetts General Hospital, and University of Minnesota School of Public Health published results from a national survey on the quality of information sharing between hospitals and SNFs to support care transitions in JAMA Open.

After a decade of investment in health IT infrastructure and new incentives to promote hospital-SNF coordination, the current state of information sharing at this critical transition is unknown. In a nationally representative survey that asked SNFs to report on information sharing from each of their two highest-volume referring hospitals, the researchers found that key information is often missing. The most prevalent types of missing information included functional, mental, and behavioral status as well as who to contact at the hospital with follow-up questions.  Information was often delayed and arrived after the patient.  Further, it was often difficult to use, with hospital discharge documents containing duplicative and extraneous information. These shortcomings across multiple dimensions of information sharing raise concerns about the hospital-to-SNF transitional care experience and potential for quality and safety challenges.

Julia Adler-Milstein, PhD, Professor of Medicine and Director of CLIIR, led the study. Dr. Adler-Milstein is a leading researcher in health IT policy with a specific focus on health information exchange and interoperability. Her work has focused on measuring information sharing across varied partners in the US healthcare system.

According to Dr. Adler-Milstein, “This study is highly novel because it offers national measures of how well information is shared when patients transition from hospitals to SNFs. While patients and their families experience this firsthand, we’ve had very little insight into what is happening systematically. Unfortunately, our results reveal major gaps that are undoubtedly contributing to real risks for the vulnerable patients making this care transition.”

When the researchers examined whether there were any hospital or SNF characteristics associated with better information sharing, only one - having a hospital clinician on-site at the SNF - was associated with more complete, timely, and usable information sharing. Surprisingly, other factors, such as having a hospital-SNF collaborative or hospital participation in an Accountable Care Organization that should motivate efforts to improve care transitions, were not consistently associated with better information sharing. 

Dr. O’Malley is a geriatrician and served as Medical Director for several SNFs in and around Boston, MA. He reflects that “sadly, this study demonstrates the dangerous and disappointing performance of a significant number of hospitals.  These failures are experienced daily by SNF-based clinicians. More concerning yet, our results likely reflect the best case scenario because we only asked SNFs to report on their high-volume hospitals; information sharing is likely to be even worse in lower volume hospital-SNF pairs. These findings point emphatically to the need for a national standard for hospital to SNF communication for content, timeliness, and format.”

Dr. Cross, whose work examines strategies to improve information sharing during care transitions, notes key learnings for health systems seeking to improve care transitions. “While overall information sharing quality was disappointing, we nonetheless found hospitals that are doing this well. For example, quite a few hospitals are using templates for discharge documents that are tailored to SNF information needs. This is an easily scalable strategy that could help improve information sharing.”   

“This important study confirms the need for Age-Friendly Health Systems that prevent harm and focus on what matters to older adults across the entire continuum of care, from hospital to skilled nursing facility to home,” said Terry Fulmer, PhD, RN, FAAN, president of The John A. Hartford Foundation, which funded the study. “Given the enormous investments in health information technology, it is unacceptable that timely, useable information is not shared across settings of care.”

About UCSF

The University of California, San Francisco (UCSF) is exclusively focused on the health sciences and is dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. UCSF Health, which serves as UCSF’s primary academic medical center, includes top-ranked specialty hospitals and other clinical programs, and has affiliations throughout the Bay Area.

The Center for Clinical Informatics and Improvement Research is a collaborative research center that seeks to discover how to leverage digital systems and data to improve health system performance at scale.  UCSF and CLIIR have an established track record of producing influential research, with a particular focus on topics relevant to the care of older adults.

About The John A. Hartford Foundation

This work was supported by The John A. Hartford Foundation (JAHF), a private, nonpartisan, national philanthropy dedicated to improving the care of older adults. The leader in the field of aging and health, the Foundation has three priority areas: creating age-friendly health systems, supporting family caregivers, and improving serious illness and end-of-life care. For more information, visit


Link to full JAMA article