Connect‐Home: Transitional Care of Skilled Nursing Facility Patients and their Caregivers

Abstract

BACKGROUND Older adults that transfer from skilled nursing facilities (SNF) to home have significant risk for poor outcomes. Transitional care of SNF patients (i.e., time-limited services to ensure coordination and continuity of care) is poorly understood. OBJECTIVE To determine the feasibility and relevance of the Connect-Home transitional care intervention, and to compare preparedness for discharge between comparison and intervention dyads. DESIGN A non-randomized, historically controlled design enrolling dyads of SNF patients and their family caregivers. SETTING Three SNFs in the Southeastern United States. PARTICIPANTS Intervention dyads received Connect-Home; comparison dyads received usual discharge planning. Of 173 recruited dyads, 145 transferred to home, and 133 completed surveys within 3 days of discharge. INTERVENTION The Connect-Home intervention consisted of tools and training for existing SNF staff to deliver transitional care of patient and caregiver dyads. MEASUREMENT Feasibility was assessed with a chart review. Relevance was assessed with a survey of staff experiences using the intervention. Preparedness for discharge, the primary outcome, was assessed with Care Transitions Measure-15 (CTM-15). RESULTS The intervention was feasible and relevant to SNF staff (i.e., 96.9% of staff recommended intervention use in the future). Intervention dyads, compared to comparison dyads, were more prepared for discharge (CTM-15 score 74.7 vs. 65.3, Mean Ratio 1.16, 95% CI: 1.08, 1.24). CONCLUSION Connect-Home is a promising transitional care intervention for older patients discharged from SNF care. The next step will be to test the intervention using a cluster randomized trial, with patient outcomes including rehospitalization.

What does it take to scale‐up a complex intervention? Lessons learned from the Connect‐Home transitional care intervention

“…At the end of Pilot Study 1, outcomes indicated that implementation strategies were successful. Most staff reported that Connect‐Home was acceptable, the intervention reached 100% of the eligible patients ( N = 68) and for the patients reached, staff maintained fidelity to greater than 80% Connect‐Home's core elements (Toles et al, ). In addition, findings provided initial support for Connect‐Home's effectiveness; compared with controls, patients and caregivers who received the intervention were significantly more prepared to continue and coordinate the patient's care at home (Toles et al, ).…”

“…Connect‐Home is one of the first transitional care interventions to focus on the transition from SNFs to home. In contrast to usual discharge planning and its focus on patient education and referral, Connect‐Home actively engages both the patient and their primary caregiver and builds their capacity to manage patient care at home (Toles, Colon‐Emeric, Naylor, Asafu‐Adjei, & Hanson, ). Table provides an overview of the core components of the Connect‐Home intervention.…”

“…Following the initial development of Connect‐Home, the research team conducted three pilot studies of the intervention. In Pilot Study 1, the team tested the feasibility, acceptability, and preliminary efficacy of the intervention in three SNFs (Toles et al, ). In Pilot Study 2, the team completed a sustainability pilot study of Connect‐Home in the three initial SNFs (Toles & Leeman, ).…”

“…In Pilot Study 1, the team tested the feasibility, acceptability, and preliminary efficacy of the intervention in three SNFs (Toles et al, ). In Pilot Study 2, the team completed a sustainability pilot study of Connect‐Home in the three initial SNFs (Toles & Leeman, ). In Pilot Study 3, the team conducted a scale‐up pilot study of Connect‐Home across SNFs in four states.…”

Evaluating the impact of a home-based rehabilitation service on older people and their caregivers: a matched-control quasi-experimental study

“… 9 Moreover, the locations of those who deliver rehabilitation care have to match the needs of the older patients. 4 Systematic reviews showed a heterogeneous impact of the location of those who provide rehabilitation care. 3 , 10 However, another systematic review claimed that patients have demonstrated better physical function, cognition, quality of life, and higher satisfaction with home-based rehabilitation service (HBRS) compared with in-patient rehabilitation services.…”