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Unplanned 30-day hospital readmissions are an important measure of hospital quality and a focus of national regulations. Skilled nursing facilities (SNFs) play an important role in the readmission process, but few studies have examined the factors that contribute to readmissions from SNFs, leaving hospitalists and other hospital-based clinicians with limited evidence on how to reduce SNF readmissions. We interviewed 28 clinicians at 15 SNFs. The interviews covered 24 patient readmissions. SNF clinicians described a range of procedural, technological, and cultural contributors to unplanned readmissions. Commonly cited causes of readmission included a lack of coordination between emergency departments and SNFs, poorly defined goals of care at the time of hospital discharge, acute illness at the time of hospital discharge, limited information sharing between a SNF and hospital, and SNF process and cultural factors.SNF clinicians identified a broad range of factors that contribute to readmissions. Addressing these factors may mitigate patients' risk of readmission from SNFs to acute care hospitals.
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