Written by Ashley Kaminski, DNP, APRN, AGACNP-BC and Holly Chaffee, MSN, BSN, RN
Care transitions remain one of the most persistent challenges in our healthcare system. Whether it’s moving from the hospital to home care, from the hospital to a skilled nursing facility (SNF), or from a SNF to home care, getting it right is often a struggle. Delayed or poor care transitions lead to increased readmission risk, mortality, and 90-day costs. Despite current efforts, patients are often discharged home without a clear plan. This situation ultimately drives worse outcomes for patients and lower Quality Measures.
Background and Literature Review
According to a retrospective cohort study by Toles et al. (2014), after being discharged from a SNF to home, approximately 22.1% of older adults had acute-care needs within 30 days. Readmissions cost Medicare $26 billion annually, with $17 billion considered avoidable (Boozary, Manchin, & Wicker, 2015). Given the shift to SNF Value-Based Purchasing by the Centers for Medicare & Medicaid Services (2017) that focuses on incentives and penalties based on performance, the push to strengthen post-acute outcomes continues to be critical.
Despite the lack of robust literature on post-acute and community-based care, some common themes highlight both areas that need improvement and persistent gaps in care. The suggestions include dealing with the challenges of the transition process by implementing a standardized tool (Toles, Frerichs, & Leeman, 2021), identifying knowledge gaps in the workforce and providing training (Gassas, 2021), and developing individualized care plans (Patrias, 2007). Significant efforts and progress have been made in creating a care transitions tool, most notably the Connect-Home intervention program. This initiative focuses on a care template, toolkit, and on-site training to improve the management of a patient’s serious illness in the home setting (Toles et al., 2014). Several studies document that further testing is needed before large-scale implementation, but it seems like a promising tool.
When looking at the gaps in knowledge across post-acute and community-based care, the documentation is clearer, indicating where staff are falling short and where improvements are most needed. One outstanding topic is better dementia training, consistently identified as an area with significant gaps that directly affect the quality of care and outcomes for patients with cognitive impairments. Certified nursing assistants receive little to no training specific to dementia care, which may be associated with neglect and abuse in SNFs (Travers Altizer et al., 2025).
Dementia care is only one example of many systemic educational deficiencies. Additional topics are medication reconciliation at care transitions, early identification of clinical deterioration, and understanding and recognition of the need for palliative care and/or hospice. In a recent study conducted by Columbia University published in Home Healthcare Now, nearly half of the caregivers surveyed had heard of palliative care but only “13% had sufficient knowledge of it” (Chastain et al., 2025). These training shortfalls lead to fragmented care, increased readmissions, and missed opportunities to best align care with the patient’s goals.
Rationale for Joint Educational Interventions
Despite similar goals and often a shared patient population, SNFs and home health agencies (along with larger health systems such as hospitals) operate in silos, resulting in disjointed care. These breakdowns become especially clear during care transitions when limited knowledge and poor communication can lead to missed needs and avoidable mistakes. Joint educational interventions represent an underutilized but high-impact strategy to bridge these divides and improve patient outcomes. The World Health Organization (2010) states, “Interprofessional education occurs when two or more professionals learn about, from, and with each other to enable effective collaboration and improve health outcomes.”
Collaborative education and training promote a unified approach that empowers staff with shared competencies and enhances interprofessional communication. Participation in joint training builds relationships across agencies to create a true culture of partnership rather than just a referral. Additionally, working together across agencies helps teams better understand each other’s roles, making it easier to stay connected and provide more consistent care for patients.
Proposed Models of Collaboration
One barrier in promoting interagency collaboration is finding a model that’s both scalable and practical for all organizations involved. It must be flexible enough to account for differences in staffing, locations, and each agency’s unique needs. Two practical starting points are cross-training during staff onboarding and offering joint in-service sessions, such as “lunch and learns.”
Using cross-training, new staff could gain a clearer understanding of each setting’s roles, limitations, and care responsibilities. This exposure would help bridge the gap between settings and build mutual respect starting on the first day on the job.
SNF employees would be introduced to home health, palliative care, and hospice services, including the types of care that can realistically be delivered in the home while recognizing that it may vary between agencies. They would also gain a clearer understanding of eligibility criteria and the scope of services offered at each level of care. Staff would be exposed to common postdischarge challenges, such as delays in medication delivery, equipment delivery and setup, and caregiver readiness. This knowledge would help support more appropriate referrals and smoother handoffs along the care continuum.
Conversely, home health clinicians would have the opportunity to observe SNF workflows, regulatory requirements, and the discharge planning process. Seeing patients at a facility before they come home offers staff the ability to be proactive in identifying potential gaps in care. This mutual understanding fosters more informed communication, shared accountability, and ultimately, better patient outcomes.
This model can be integrated into current orientation structures by allowing one to two days of shadowing, in addition to any applicable written materials for learning. Thus the groundwork is laid for greater role clarity, increased appreciation of the healthcare system, and improved continuity of care across the spectrum.
Another option is hosting joint in-services, like a “lunch and learn” series. These sessions can rotate between agencies or departments and be offered either in person or virtually, depending on what works best for the group. They can be kept short and scheduled during shift changes, lunch breaks, or just after the end of the workday, led by educators, supervisors, or case managers. Each session can be tailored to address common challenges or areas of interest shared across teams, creating a space for open dialogue, team-based learning, and collaboration. This approach not only helps strengthen interagency relationships but also encourages team members to see each other as resources and partners in care. Over time, these in-services can build trust, improve communication, and support better patient outcomes.
Note: AAPACN members have access to the Discharge Planning for Licensed Staff In-Service Education, which can also assist home care staff to understand the SNF discharge process and how SNFs develop a discharge plan to help residents make a safe transition home.
Barriers to Implementation
The benefits of interagency collaboration and joint education are clear, but implementing these models can be challenging. Workforce shortages and increased caseloads are evident hurdles, often limiting the time and resources for staff education while not compromising patient care. Given that continuing education opportunities are associated with increased retention, in time this model should help overcome these obstacles (Shiri et al., 2023). Additionally, variations in agency structure, documentation systems and expectations, and regulatory mandates add complexity and create further barriers to implementing joint initiatives.
To overcome these difficulties, several strategies are suggested: starting small, using virtual platforms, identifying champions, and analysis of metrics. To start small, leadership can host a lunch and learn session exclusively for nursing staff, focusing on a relevant topic such as medication reconciliation. Based on feedback, perceived value, and feasibility, the sessions can then be expanded to other professions. Leveraging virtual platforms, as able, allows a flexible schedule and location, likely attracting a larger audience. Recognizing and empowering internal champions for each agency could support the coordination of each session and the ability to gather feedback and promote momentum. Lastly, in monitoring and comparing quality metrics, return on investment can be demonstrated, thus reinforcing long-term value.
Conclusion and Next Steps
As our healthcare system continues to evolve and shift toward value-based purchasing, joint educational opportunities have limitless potential for SNFs and home health agencies to work together and revolutionize healthcare delivery. Through collaboration, clinicians will be better prepared to coordinate care and facilitate smooth care transitions, reduce redundancies and errors, and be proactive.
This approach is equally important for leaders and patient-facing clinicians. Developing and providing opportunities for staff across various settings to learn and grow together strengthens their knowledge, trust, and accountability. Fostering a culture of collaboration is essential in today’s highly complex healthcare landscape, where high-quality outcomes are constantly demanded for sustainability.
The next steps in developing the joint training model, such as lunch and learns, begin by identifying and partnering with aligned external agencies. Through a review of metrics, mission alignment, and discussions with key stakeholders, leadership can engage the right partners and begin collaborative planning. Training content should address shared priorities, ensure equitable resource contribution, and include mechanisms for feedback and evaluation to support long-term impact and sustainability. By committing to collaboration, leaders invest in advancing care across the continuum and improving patient outcomes.
References
Boozary, A.S., Manchin, J., & Wicker, R.F. (2015). The Medicare hospital readmissions reduction program: Time for reform. Journal of the American Medical Association, 314(4), 347–348.
Centers for Medicare & Medicaid Services. (2017). The skilled nursing facility value-based purchasing program (SNF VBP). https://www.cms.gov/medicare/quality/nursing-home-improvement/value-based-purchasing
Chastain, A.M., Shang, J., Murali, K.P., et al. (2025). Development of and testing novel questionnaires assessing palliative care–related knowledge, attitudes, and confidence among home healthcare clinicians, patients, and caregivers. Home Healthcare Now, 43(1), 21–31.
Gassas, R. (2021). Sources of the knowledge-practice gap in nursing: Lessons from an integrative review. Nurse Education Today, 106, 105095.
Patrias, K. (2007). Citing medicine: The NLM style guide for authors, editors, and publishers (2nd ed.). National Library of Medicine.
Shiri, R., El-Metwally, A., Sallinen, M., Pöyry, M., Härmä, M., & Toppinen-Tanner, S. (2023). The role of continuing professional training or development in maintaining current employment: A systematic review. Healthcare, 11(21), 2900.
Toles, M., Colon-Emeric, C., Naylor, M.D., Asafu-Adjei, J., & Hanson, L.C. (2014). Connect-Home: Transitional care of skilled nursing facility patients and their caregivers. Journal of the American Geriatric Society, 62(4), 633–639.
Toles, M., Frerichs, A., & Leeman, J. (2021). Implementing transitional care in skilled nursing facilities: Evaluation of a learning collaborative. Geriatric Nursing, 42(4), 863–868.
Travers Altizer, J.L., Reckrey, J.M., Frogner, B.K., Grabowski, D.C., & Spetz, J. (2025). The dementia care workforce: Essential to care but large research gaps exist. Alzheimer’s Dementia, 21(5), e70269.
World Health Organization. (2010). Framework for action on interprofessional education & collaborative practice. https://www.who.int/publications/i/item/framework-for-action-on-interprofessional-education-collaborative-practice
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