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

Transitional Care for Post-Acute Care Patients in Nursing Homes

Mark Toles, MSN, RN


Acknowledgements
Acknowledgements

  • Duke University School of Nursing

  • John A. Hartford Foundation

  • Ruth Anderson, PhD, RN, FAAN


Research goal
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
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
Healthcare transitions after hospitalization

SNF Patients

25% in SNF after 30 days

11%

re-hospitalized

53% home

11% home with complications

Coleman et al., 2004


How do we improve care transitions
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
Transitional care interventions

Added Staff

e.g.,

APRNs

Care Processes

e.g.,

inpatient & home visits

engage caregivers

create transition plan

teach medications

transfer information

Outcomes

e.g.,

reduced

rehospitalization

&

reduced healthcare cost


Research needs
Research needs

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

Ask

Where do gaps occur?

What are outcomes?

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

Ask

What staff interact?

How often do staff interact?


Feasibility study
Feasibility study

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

Findings

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

Structure

Care Processes

Outcomes

Interactions

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


Structure
Structure

Stable facility-level features that support care processes

Examples

1. Care-team members

2. Procedure for sending records to community provider

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


Care processes
Care processes

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

Examples

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


Interactions
Interactions

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

Examples

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.


Outcomes
Outcomes

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

Examples

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
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
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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