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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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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.