The Transition of Elderly Patients Between Hospitals and Nursing Homes: Improving Nurse-to-Nurse Communication

Abstract

Lack of patient information is a particular problem when a patient is transferred from one health care facility to another. The lack of information needed to develop a timely and effective plan of care for an older adult transferred to the nursing home facility may exacerbate disruptions in the older adult's care. Also, adjustment or readjustment to the nursing home or hospital environment may be prolonged. Persistence of problems or difficulty in adjustment may then lead to exacerbation of the disease processes and, ultimately, hospital readmissions. Evidence suggests that elderly patients discharged from the hospital have high readmission rates. Although the patient is most affected by a breakdown in communication, everyone in the nursing home involved in the resident's care is also affected. All staff who provide care to the resident, including nursing, medicine, nutrition, pharmacy, social work, and physical therapy staff members, must be cognizant of issues related to communication for patients being transferred. In this article, the authors discuss the development, implementation, and results of a model designed to increase the communication surrounding the transition of elderly patients from an inpatient unit to and from nursing homes.

Health Information Technologies: Which Nursing Homes Adopted Them?

“…46e48 Approximately 10% of patients arrive at SNFs without information and 30% arrive with inconsistent information under paper-based recordkeeping. 49 Under these circumstances, patients are highly vulnerable to adverse events, such as injuries, falls, infections acquired in health care settings, pressure ulcers, hip fractures, medical errors, and more. 50 Many of these issues may result in re-hospitalization, further raising the risk of care problems on future transfers.…”

The Role of Head Nurse on Communication: A Social Network Approach

“…Poor communication among physicians and nursing staff often negatively impact patient care quality, especially during patient care or transferring processes. The effects of poor communication may cause harm to patients [5], [6]. As a result, effective and good communication is the basis for providing quality patient care and ensuring patient safety.…”

Characterizing “information transfer” by using a Joint Cognitive Systems model to improve continuity of care in the aged

“…Multiple solutions to improve transitions in care have been proposed and selectively tested. Such solutions include care coordination (13 of 15 randomized trials showed no significant differences in subsequent hospitalizations and net savings) [15], the development of discharge checklists for hospitalists based on expert opinion [16], improved nurse to nurse communication using patient transition information checklists [17], and a movement towards information transfer interoperability [18][19][20]. There remains however, a lack of standardization of the necessary information data elements and processes as effective strategies to improve patient outcomes.…”