The Importance of an Interdisciplinary Approach in the Transition of At-Risk Patients From Hospital to Skilled Nursing Facilities: A Case Report

Significant gaps exist in the transition of care for patients from acute hospitalization to skilled nursing facilities. Amongst the several well-studied interventions that exist to improve the transition of care, few investigate the efficacy of using an interdisciplinary team (IDT) approach. Here, we report the case of a 78-year-old man with a complicated social situation who had a successful medical and social transition of care from the hospital to the skilled nursing facility (SNF) with an IDT meeting that entailed the collaboration of hospital and SNF physicians and social workers.