Transitional care for post acute care patients in nursing homes
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Transitional Care for Post-Acute Care Patients in Nursing Homes. Mark Toles, MSN, RN. Acknowledgements. Duke University School of Nursing John A. Hartford Foundation Ruth Anderson, PhD, RN, FAAN. Research goal.

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Transitional Care for Post-Acute Care Patients in Nursing Homes

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Transitional Care for Post-Acute Care Patients in Nursing Homes

Mark Toles, MSN, RN


  • Duke University School of Nursing

  • John A. Hartford Foundation

  • Ruth Anderson, PhD, RN, FAAN

Research goal

From 1999-2007, the number of post-acute care patients in nursing homes increased from 1.4 million to 1.8 million patients (32%).

Transitional care has rarely been studied for these patients.

Prepare older adults who receive post-acute care in nursing homes for safe transitions from nursing homes to home.

Post-acute care patients in nursing homes

1. Compared to patients who discharge from hospitals to home, they have…

- older age

- hip fracture, stroke, chronic illness

- ADL dependence

2. Nursing homes may lack skills and resources for providing transitional care

Healthcare transitions after hospitalization

SNF Patients

25% in SNF after 30 days



53% home

11% home with complications

Coleman et al., 2004

How do we improve care transitions?

Transitional care

“the set of actions designed to ensure coordination and continuity of care between providers and settings of care”

(American Geriatrics Society, 2003)

Transitional care interventions

Added Staff



Care Processes


inpatient & home visits

engage caregivers

create transition plan

teach medications

transfer information






reduced healthcare cost

Research needs

Describe transitional care for post-acute patients in nursing homes.


Where do gaps occur?

What are outcomes?

Describe how care-team interactions foster or impede transitional care.


What staff interact?

How often do staff interact?

Feasibility study

I searched for the best way to study transitional care as it is provided by existing staff in nursing homes.


1. Study transitional care over full post-acute care admission

2. Use Structure-Process-Interactions-Outcomes Framework

3. Identify gaps and inconsistencies in care

Transitional Care in a Nursing Home


Care Processes



Model based: (a) Donabedian’s Model of Health Care Quality, (b) Naylor’s Transitional Care Model, (c) Anderson’s Model of Local Interaction Strategies


Stable facility-level features that support care processes


1. Care-team members

2. Procedure for sending records to community provider

3. 21 - 28 day length of stay (Medicare reimbursed)

Care processes

Care-team task work aimed at preparing post-acute care patients for discharge and self care at home


1. Develop a transition plan with patients & caregivers

2. Teach patients about medications & treatments

3. Draft a written care plan

4. Transfer medical information to community providers


Staff behaviors which promote or impede effective use of transitional care processes


1. A staff member who asks another,

“What does that mean?”

Verification increases information exchange.

2. Staff members who informally gather

to discuss a patient.

Feedback loops improve sensemaking.


Direct, patient-centered measurements of the effects of transitional care processes


1. Yes or No: was information transferred from

the nursing home to the primary care physician?

2. Patients’ verbal descriptions of things they have learned to do which facilitate bathing at home.

Why does any of this matter?

  • Case Example

  • 86 year old patient with new knee replacement

  • Active family

  • Optimistic patient

  • Surgical site well-healed

  • Good rehabilitation potential

  • - High risk for falling

Discover gaps in care that we can fix

Structure:Excellent, multi-disciplinary team; daily team meeting focused on utilization.

Process: OT & Patient plan equipment needs; No written planning.

Interactions: OT & Nursing poorly connected;

OT & family communication is limited.

Outcome:Patient feels prepared for life at home;

Error: goes home without shower bench.

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