Shah N - With the aim at decreasing the 30-day all-cause readmission rate at an urban medical center for skilled nursing facility discharges from the collaborative from Accountable Care Unit from 18% in 2018 to 16% from April to December 2019 at the largest teaching campus for the health system, researchers sought the factors that influence readmission of patients with chronic illness being managed at Skilled Nursing Facilities and investigated the key drivers that improved communication will try to achieve by the warm handoff protocol. Further, the creation of a comprehensive discharge packet was described with a relevant summary of the hospital course. Employing palliative care training, the communication between 2 facilities was improved. Lack of verbal communication/wound care orders/nutrition and feeding orders/comprehensive discharge summary/advance directives were some of the potential Key Drivers for the readmissions. Change Concepts devised incorporate a warm handoff between the discharging team and receiving team at SNF, building a comprehensive discharge packet, improve the hospital course in the discharge summary, build a standardized system for discharge to a skilled nursing facility. As per the results of PDSA Cycle 1 and 2, there was a decrease of 40% for the readmissions in correltion with warm handoff and creating a comprehensive discharge packet. While PDSA Cycle 2 is ongoing, researchers are in process of PDSA Cycle 3. Based on outcomes, the aim was achieved in the initial PDSA Cycle by implementing the palliative care skills by improving communication between 2 facilities. Recognition of other factors and reduction in readmission for chronically ill nursing home patients at their urban medical center are ongoing.