Montefiore Medical Center’s Regional Nursing Home Collaborative: Innovations in Post-Acute Care Transitions and Reductions in Readmissions

Resource ID Posted Format
549 September 14, 2012 Reference
Montefiore Medical Center, University Hospital for Albert Einstein College of Medicine


This resource describes a collaboration between skilled nursing facilities (SNF) to reduce avoidable readmissions of patients discharged from the acute care setting to a SNF. The collaboration sought to increase knowledge of evidence-based guidelines, improve communication between acute and post acute providers, improve the quality of care and quality of life for patients, and reduce preventable acute care readmissions.

*2012 Readiness for Reform (R4R) Innovation Challenge


  1. Facilitate and support the training of geriatrics fellows within the Einstein-Montefiore Geriatrics Fellowship Program by providing exposure to innovative programs both within the geriatric inpatient setting and the post-acute care SNF setting.
  2. Improve care for patients by leveraging research findings produced by Einstein to identify gaps in care at Montefiore and among SNFs in the Bronx Community.
  3. Establish new best practices in care management and communication that are immediately folded into programs for medical students, residents, and fellows training in internal and family medicine and geriatrics, as one mechanism to meet ACGME requirements for the Next Accreditation System (NAS), to prepare graduates for the “future” health care delivery system.


  • 2012 Readiness for Reform (R4R) Innovation Challenge, Care Transitions, Nursing Home/Skilled Nursing Facility, Cross-Institutional Provider Collaboration, Best Practices, Knowledge Transfer, Readmissions, Advanced Care Planning, Geriatrics

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