Background: Nationally, 20% of patient readmissions occur within the first 48 hours after arrival to a skilled nurse facility (SNF), and 40-68% of these readmissions are potentially avoidable. Since 2016, the Centers for Medicare and Medicaid penalized SNFs when their return to hospital (RTH) percentages was above national benchmarks. The four SNFs in this project experienced rising transfer rates and diminished RTH percentages since 2017, despite using in-house providers Monday through Friday. Furthermore, there was no provision to address patients’ changes in conditions after hours.

Purpose: This evidence-based practice (EBP) project aimed to standardize the care provided to SNF patients with a change of condition, resulting in less traumatic transfers to higher levels of care.

Methods: Using the EBP process, an evidence-based intervention was derived from the synthesized body of evidence. The standardized protocol called Call Us First (CUF) was implemented when a change in resident condition and included a telemedicine (TM) component. Contacting a TM provider enabled real-time care for residents with the expected outcome of reduced transfers to the emergency department (ED) and subsequent reduction of RTH.

Results: Two of the four SNFs met or exceeded the expected reduction in RTH of 4-11%; however, they did not reduce transfers to the ED. Sustainability of Call Us First requires an onsite champion, collaborative presence, and clear communication of the implementation plan. Call Us First has continued as a care standard to help staff nurses reduce transfer trauma, improve patient outcomes, and increase facility reimbursement.

Date of publication

Spring 5-2-2022

Document Type

DNP Scholarly Project



Persistent identifier


Committee members

Ellen Fineout-Overholt, PhD, Cheryl Parker, PhD


Doctor of Nursing Practice