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.
Mark Toles, MSN, RN
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.
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
25% in SNF after 30 days
11% home with complications
Coleman et al., 2004
“the set of actions designed to ensure coordination and continuity of care between providers and settings of care”
(American Geriatrics Society, 2003)
inpatient & home visits
create transition plan
reduced healthcare cost
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?
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
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-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.
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.