Nurses' Role in Managing "The Fit" of Older Adults in Skilled Nursing Facilities.

Post-acute care for older adults often involves transfer to a skilled nursing facility (SNF) following hospital discharge. This transition is often poorly coordinated and leaves older adults at risk for poor health outcomes, but new payment models offer opportunities to align improved care practices with payments. There is a dearth of evidence regarding the role of nursing and its potential to improve hospital to SNF care transitions. Ninety-nine semi-structured interviews were conducted with clinicians, patients, and caregivers from three hospitals and three SNFs. Results indicate a sharp contrast in the roles of hospital nurses-who are often silent partners in post-acute care decision making-and SNF nurses, who take a primary role as managing "the fit" for patients transitioning to a SNF. Nurses are uniquely positioned to make needed changes to culture to adapt to new payment models and improve patient outcomes. [Journal of Gerontological Nursing, 43(12), 11-20.].