Care Management and the transition of older adults from a skilled nursing facility back into the community

Adam G. Golden, Shanique Martin, Melanie da Silva, Bernard A. Roos

Research output: Contribution to journalArticle

13 Scopus citations


After hospitalization, many older adults require skilled nursing care. Although some patients receive services at home, others are admitted to a skilled nursing facility. In the current fragmented health care system, hospitals are financially incentivized to discharge frail older adults to a facility for postacute care as soon as possible. Similarly, many skilled nursing facilities are incentivized to extend the posthospitalization period of care and to transition the patient to custodial nursing home care. The resulting overuse of institution-based skilled nursing care may be associated with various adverse medical, social, and financial consequences. Care management interventions for more efficient and effective skilled nursing facility use must consider the determinants involved in the decisions to admit and maintain patients in skilled nursing facilities. As we await health care reform efforts that will address these barriers, opportunities already exist for care managers to improve the current postacute transition processes.

Original languageEnglish
Pages (from-to)54-59
Number of pages6
JournalCare Management Journals
Issue number2
StatePublished - Jul 11 2011
Externally publishedYes



  • Care coordination
  • Home- and community-based services
  • Hospital
  • Medicare/Medicaid

ASJC Scopus subject areas

  • Health Policy

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