Fixing the SNF-to-Hospital Cycle with Palliative Care

The cycle of patients moving from skilled nursing facilities (SNFs) to hospitals and back is a significant issue in healthcare. This cycle not only impacts patient well-being but also strains healthcare resources. Palliative care offers a promising solution to this problem by providing comprehensive, patient-centered care that addresses both medical and emotional needs.

The SNF-to-Hospital Cycle

Patients in SNFs often experience a recurring cycle of hospital admissions due to various health complications. These frequent transfers can be distressing for patients and families, and they contribute to increased healthcare costs. The cycle is driven by several factors, including the complexity of patients’ medical conditions, lack of proper management in SNFs, and the absence of advance care planning.

The Role of Palliative Care

Palliative care focuses on improving the quality of life for patients with serious illnesses by managing symptoms, providing psychosocial support, and coordinating care. Unlike hospice care, which is typically reserved for patients nearing the end of life, palliative care can be provided alongside curative treatments at any stage of illness.

By integrating palliative care into SNFs, patients can receive continuous, comprehensive care tailored to their individual needs. This approach helps manage symptoms more effectively, reducing the likelihood of acute exacerbations that necessitate hospital admissions.

Benefits of Palliative Care in SNFs

  1. Symptom Management: Palliative care teams are skilled in managing complex symptoms such as pain, shortness of breath, and nausea. Effective symptom control can prevent the need for emergency hospital visits.
  2. Advance Care Planning: Palliative care encourages discussions about patients’ goals and preferences, leading to better advance care planning. Clear directives can guide care decisions and reduce unnecessary hospitalizations.
  3. Holistic Support: Palliative care addresses not only physical symptoms but also emotional, social, and spiritual needs. This holistic approach improves overall patient satisfaction and quality of life.
  4. Care Coordination: Palliative care teams work closely with other healthcare providers to ensure coordinated and consistent care. This collaboration helps avoid gaps in care that can lead to hospital readmissions.

Implementation Strategies

To successfully integrate palliative care into SNFs, several strategies can be employed:

  • Training and Education: Providing training for SNF staff on palliative care principles and practices can enhance their ability to manage complex cases and provide high-quality care.
  • Collaboration with Palliative Care Providers: Establishing partnerships with local palliative care providers can facilitate access to specialized services and support.
  • Telemedicine: Utilizing telemedicine can extend the reach of palliative care teams, allowing them to provide consultations and support remotely.
  • Policy and Reimbursement: Advocating for policies that support the inclusion of palliative care in SNFs and ensuring adequate reimbursement for these services are crucial for sustainability.


The integration of palliative care into skilled nursing facilities has the potential to break the cycle of frequent hospital admissions, improve patient outcomes, and enhance the overall quality of care. By addressing the comprehensive needs of patients, palliative care can provide a more stable and supportive environment for those with serious illnesses. As healthcare systems continue to evolve, incorporating palliative care into SNFs should be a priority to achieve better health outcomes and more efficient use of resources.