Staff Interaction Strategies That Optimize Delivery of Transitional Care in a Skilled Nursing Facility

Toles, Mark; Barroso, Julie; Colón‐Emeric, Cathleen; Corazzini, Kirsten; McConnell, Eleanor; Anderson, Ruth A.

doi:10.1097/fch.0b013e31826666eb

Cited by 13 publications

(15 citation statements)

References 32 publications

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“…Owing to financial constraints in nursing homes, cost‐neutral strategies such as use of existing SNF staff to deliver elements of transitional care may be needed to improve patient and caregiver preparation for care transitions to home . Findings from a set of case studies of transitional care in SNFs, for example, show that frontline nursing home staff are frequently unaware of the basic components of transition planning and are thus unlikely to provide critical services such as medication reconciliation, written discharge and follow‐up instructions, or clinical summaries of the nursing home stay to the next care provider . In individuals with greatest vulnerability, for example, those with multiple comorbidities, a diagnosis of neoplasms or respiratory disease, and dual‐eligibility status, interventions such as the Transitional Care Model may be useful.…”

Section: Discussionmentioning

confidence: 99%

Restarting the Cycle: Incidence and Predictors of First Acute Care Use After Nursing Home Discharge

Toles

Anderson

Massing

et al. 2014

J American Geriatrics Society

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Background/Objectives The primary objective of this study was to describe the time to first acute-care use (e.g., emergency department use without hospitalization or rehospitalization)for older adults who discharged to home after receiving post-acute care in skilled nursing facilities (SNFs). The secondary objective was to identify predictors of patients' first acute-care use. Design Retrospective cohort study using administrative claims data. Setting SNFs providing post-acute care in North and South Carolina (N=1,474). Participants A cohort of Medicare beneficiaries aged 65 years and older (N=55,980) who were hospitalized, then transferred to a SNF for post-acute care, and subsequently discharged home (January 1, 2010, to August 31, 2011). Measurements Medicare institutional claims data (Part A and Part B) and Medicare enrollment data were used; facility-level variables were obtained from CMS Nursing Home Compare. Survival from SNF discharge to first acute-care use was explored. Cox proportional hazards regression models were used to describe patient, home care and nursing facility-level predictors. Results After SNF-to-home discharge, 22.1% of older adults had an episode of acute-care use within 30 days, including 7.25% with an ED visit without hospitalization and 14.8% with a rehospitalization; 37.5 % of older adults had their first acute-care usewithin 90 days. Male gender, dual eligibility status, higher Charlson co-morbidity score, certain primary diagnoses at the index hospitalization (neoplasms and respiratory disease), and care in SNFs with for-profit ownership or fewer licensed practical nurses hours per patient day were associated with higher risk for acute-care use. Conclusion Medicare patients have a high use of acute-care services after discharge from SNFs, and several factors associated with acute-care use are potentially modifiable. Findings suggest the need for interventions to support patients as they transition from SNFs to home.

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Section: Discussionmentioning

confidence: 99%

Restarting the Cycle: Incidence and Predictors of First Acute Care Use After Nursing Home Discharge

Toles

Anderson

Massing

et al. 2014

J American Geriatrics Society

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“…Health care professionals in acute care hospitals Elderly patients who expressed preferences for care at end of life Communication with health care professionals and documentation of these preferences remains inadequate (Heyland et al, 2013). Interactions with patients and family caregivers increased the capacity of patient care teams to optimize patient-centered care, information exchange, and coordination of transitional care (Toles et al, 2012). Nursing Imagery used by adult cancer patients to describe their experiences Nurses can find a common language for connecting with patients and can advocate for greater awareness and more sensitive communication by other health care providers (Harrington, 2012).…”

Section: Roles For Patients As Members Of Health Care Teammentioning

confidence: 99%

Patients and Health Care Teams Forging Effective Partnerships

Okun¹,

Schoenbaum²,

Andrews³

et al. 2014

NAM Perspectives

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1 interactions with health professionals and providing feedback that strengthens the relationship and their mutual understanding of the patient's needs and how they may best be addressed. Strong primary care, the care setting focused on in this paper, is critical to achieving better patient outcomes, especially as the prevalence of multiple chronic health conditions increases (AHRQ, 2014a). More than 75 percent of U.S. health care spending is devoted to treating persons with chronic conditions (CDC, 2009). Of course, specialists and subspecialists also play very important roles. The complexity of care and services often required today requires health professionals across the system to work with people in a coordinated, collaborative way and to consider the whole person-not just the condition or array of conditions that a person might have (Bodenheimer et al., 2002). All patients bring unique expertise regarding their preferences, skills, knowledge, and experiences into a potential relationship with a health care team. Patients-and, often, their families and caregivers-live with their conditions and symptoms 24 hours a day, 7 days a week. Patients are experts in knowing how they feel from moment to moment and day to day. However, not all patients are well informed about their medical conditions and how best to manage them (Fagerlin et al., 2010). Relatively few come to medical encounters with the same technical skills, clinical knowledge, and detailed understanding of the health care system that most clinicians have. Some patients prefer to be involved at a more detailed level, others less so (Alston et al., 2012). But many patients and family members have acquired, and many more are capable of developing, considerable knowledge, skills, and confidence in decision making that could influence their outcomes positively-especially those outcomes that matter most to them. Only recently, with increased attention on patient-centered care at the practice level, has it become evident that a large percentage of patients who have personal physicians and, especially minorities, do not have an effective health care team (Beal et al., 2007). When people have a personal physician and an effective practice team, their outcomes are better (Beal et al., 2007; Havyer et al., 2014). There is still much to learn about the practical realities of patients becoming true partners in their care, and the most effective teachers will be patients themselves. When patients and clinicians have an effective partnership, the relationship becomes more fluid. It transcends the traditional roles of learner and teacher, leader and follower. Valid, ongoing assessments of team functioning and performance, including assessments by patients themselves, will be important to identify and illuminate team functioning and the strength of the partnership with patients, and to inform improvement efforts so that demonstrably better patient outcomes can be achieved consistently. Methods Given the scope of the project, an early decision of the authors was to divi...

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“…2,24 Third, resource and staffing constraints in SNFs may limit the quality of services available to SNF patients and caregivers to prepare them for effective self-care at home. 4,5 Thus, unique transitional care services may be necessary to improve clinical and financial outcomes after care in SNFs.…”

Section: Discussionmentioning

confidence: 99%

“…Transitional care ideally will prepare patients and their caregivers to provide self-care and coordinate medical services after transitions from SNFs to home and other settings. 5 However, unlike transitional care for hospital discharge, transitional care from SNF to home is rarely evaluated or improved upon.…”

Section: Introductionmentioning

confidence: 99%

Transitional care of older adults in skilled nursing facilities: A systematic review

et al. 2016

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Transitional care may be an effective strategy for preparing older adults for transitions from skilled nursing facilities (SNF) to home. In this systematic review, studies of patients discharged from SNFs to home were reviewed. Study findings were assessed (1) to identify whether transitional care interventions, as compared to usual care, improved clinical outcomes such as mortality, readmission rates, quality of life or functional status; and (2) to describe intervention characteristics, resources needed for implementation, and methodologic challenges. Of 1,082 unique studies identified in a systematic search, the full texts of six studies meeting criteria for inclusion were reviewed. Although the risk for bias was high across studies, the findings suggest that there is promising but limited evidence that transitional care improves clinical outcomes for SNF patients. Evidence in the review identifies needs for further study, such as the need for randomized studies of transitional care in SNFs, and methodological challenges to studying transitional care for SNF patients.

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Staff Interaction Strategies That Optimize Delivery of Transitional Care in a Skilled Nursing Facility

Cited by 13 publications

References 32 publications

Restarting the Cycle: Incidence and Predictors of First Acute Care Use After Nursing Home Discharge

Restarting the Cycle: Incidence and Predictors of First Acute Care Use After Nursing Home Discharge

Patients and Health Care Teams Forging Effective Partnerships

Transitional care of older adults in skilled nursing facilities: A systematic review

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