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Reducing Hospitalizations in Medicare Beneficiaries

  • Need: To reduce hospital readmissions for Medicare patients in rural Kentucky and Tennessee.
  • Intervention: Two quality improvement tools called IMPACT and INTERACT helped older patients transition from Vanderbilt University Medical Center to a skilled nursing facility.
  • Results: Practitioner follow-up visits increased, while emergency department visits decreased.


Promising (About evidence-level criteria)


From 2013 to 2015, the Reducing Hospitalizations in Medicare Beneficiaries program helped older adults transition from Vanderbilt University Medical Center, located in Nashville, Tennessee, into one of 23 partnering skilled nursing facilities (SNFs). The program brought together nurse practitioners, pharmacists, research assistants, and others to compile a patient's medical information into a single document so that medical staff in Vanderbilt and the patient's SNF had all the information needed to ensure a smoother transition and better care.

Vanderbilt partnered with SNFs in the following rural communities:

  • Glasgow, KY
  • Madisonville, KY
  • Columbia, TN
  • Cookeville, TN
  • Dickson, TN
  • Lawrenceburg, TN
  • Lewisburg, TN
  • McMinnville, TN
  • Pulaski, TN
  • Smithville, TN
  • Sparta, TN
  • Springfield, TN

Reducing Hospitalizations in Medicare Beneficiaries received funding from a Centers for Medicare & Medicaid Services (CMS) Health Care Innovation Award (HCIA).

Services offered

Vanderbilt staff identified all patients with Medicare coverage who were being discharged to 23 SNFs located in rural and urban areas of Tennessee and Kentucky. The staff also identified risk factors for these patients that might lead to readmission or a visit to the emergency department. These risk factors included:

  • Cognitive impairment and/or depression
  • Delirium
  • Hyperpolypharmacy (taking 10 or more medications simultaneously)
  • Incontinence
  • Pain at discharge
  • Pressure ulcers
  • Recent falls
  • Weight loss and/or loss of appetite

To improve care for these patients and reduce their risk of re-hospitalizations, Vanderbilt integrated in-hospital and post-acute care services through the Improved Post-Acute Care Transitions (IMPACT) team and the Interventions to Reduce Acute Care Transfers (INTERACT) tool.


The IMPACT team was designed to streamline the discharge process to the patient's SNF by improving documentation as well as communication between Vanderbilt and the SNF. Vanderbilt patients were assigned to a transitions advocate (TA, usually a nurse practitioner). This TA worked with:

  • Pharmacists to compile all medication lists (from admission, in-hospital, and discharge) into one document
  • Research assistants to compile EHR information into one document: a short summary called a nursing transition summary (NuTS)
  • The patient's SNF to perform a "warm handoff" and information review of the NuTS form when the patient is discharged from Vanderbilt


INTERACT is a tool to assist SNF staff with clinical operations and facilitates staff's ability to identify issues at an earlier stage as well as providing suggested care pathways for patients that might prevent readmissions.

The full IMPACT program ended after the grant cycle, but components of the medication and transition information forms will continue. The INTERACT tool has been integrated into the partnering SNFs' clinical operations.


According to the HCIA Complex/High-Risk Patient Targeting: Third Annual Report:

  • The program reached 1,691 patients between January 2013 and June 2015.
  • Emergency department visits decreased by 70 per 1,000 discharges per quarter.
  • 30-day practitioner follow-up visits increased to 58 per 1,000 discharges per quarter.
  • There was a 5% reduction in 30-day hospital readmissions, although not statistically significant.

Findings from the CMS award led to two randomized controlled trials (listed in Vanderbilt Center for Quality Aging projects) to implement a patient-centered deprescribing intervention during the hospital stay for older patients discharged to area SNFs. The Shed-MEDS clinical trial is funded by the National Institute of Aging, and the Drug Reduction in Older Patients trial is funded by the VA Health Services Research & Development.

For more information on program results:

Petersen, A.W., Shah, A.S., Simmons, S.F., Shotwell, M.S., Jacobsen, J.M.L., … & Vasilevskis, E.E. (2018). Shed-MEDS: Pilot of a Patient-Centered Deprescribing Framework Reduces Medications in Hospitalized Older Adults Being Transferred to Inpatient Postacute Care. Therapeutic Advances in Drug Safety, 9(9), 523-533.

Vasilevskis, E.E., Ouslander, J.G., Mixon, A.S., Bell, S.P., Jacobsen, J.M.L., Saraf, A.A., … & Schnelle, J.F. (2017). Potentially Avoidable Readmissions of Patients Discharged to Post-Acute Care: Perspectives of Hospital and Skilled Nursing Facility Staff. Journal of American Geriatric Society, 65(2), 269-276.

Jacobsen, J.M.L., Schnelle, J.F., Saraf, A.A., Long, E.A., Vasilevskis, E.E., Kripalani, S., & Simmons, S.F. (2017). Preventability of Hospital Readmissions from Skilled Nursing Facilities: A Consumer Perspective. The Gerontologist, 57(6), 1123-1132.

Simmons, S.F., Schnelle, J.F., Saraf, A.A., Coelho, C.S., Jacobsen, J.M.L., Kripalani, S., … & Vasilevskis, E.E. (2016). Pain and Satisfaction with Pain Management among Older Patients during the Transition from Acute to Skilled Nursing Care. The Gerontologist, 56(6), 1138-1145.

Bell, S.P., Vasilevskis, E.E., Saraf, A.A., Jacobsen, J.M.L., Kripalani, S., Mixon, A.S., … & Simmons, S.F. (2016). Geriatric Syndromes in Hospitalized Older Adults Discharged to Skilled Nursing Facilities. Journal of the American Geriatrics Society, 64(4), 715-722.

Simmons, S.F., Bell, S., Saraf, A.A., Coelho, C.S., Long, E.A., Jacobsen, J.M.L., … & Vasilevskis, E.E. (2016). Stability of Geriatric Syndromes in Hospitalized Medicare Patients Discharged to Skilled Nursing Facilities. Journal of the American Geriatrics Society, 64(10), 2027-2034.

Saraf, A.A., Peterson, A.W., Simmons, S.F., Schnelle, J.F., Bell, S.P., Kripalani, S., … & Vasilevskis, E.E. (2016). Medications Associated with Geriatric Syndromes (MAGS) and their Prevalence in Older Hospitalized Adults Discharged to Skilled Nursing Facilities. Journal of Hospital Medicine, 11(10), 694-700.


The SNF patient population is very frail and has numerous problems that are difficult to address in either the hospital or SNF. One of these problems is hyperpolypharmacy: Patients were discharged from the hospital and the SNF with an average of 15+ medications. Efforts are underway at Vanderbilt and the Nashville VA to reduce medications prior to hospital discharge, which might make care in the SNF less problematic and improve outcomes. This and similar interventions should be equally effective with urban and rural patients.


Florida Atlantic University, which helped develop INTERACT, provides INTERACT training webinars to Vanderbilt and the SNFs. The INTERACT website provides other resources.

Contact Information

Craig Boerner, National News Director
Vanderbilt University Medical Center

Care coordination
Elderly population
Long-term care

States served
Kentucky, Tennessee

Date added
June 23, 2017

Date updated or reviewed
May 2, 2022

Suggested citation: Rural Health Information Hub, 2022. Reducing Hospitalizations in Medicare Beneficiaries [online]. Rural Health Information Hub. Available at: [Accessed 6 February 2023]

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.