Hospitals, SNFs team to prevent readmissions.

Duke Raleigh Hospital participates in a community-wide collaborative of hospitals and post-acute providers but also has developed close relationships with individual skilled nursing facilities. Discussions resulted in nurse-to-nurse reports when patients transition. The hospital staff provided education on peripherally inserted central catheter (PICC) line care and wound care to nursing home staff. SNFs alert the hospital team when patients are being transported to the emergency department.