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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
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.
Post-acute care patients in nursing homes
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
Healthcare transitions after hospitalization
SNF Patients
25% in SNF after 30 days
11% re-
hospitalized53% home
11% home with
complications
Coleman et al., 2004
How do we improve care transitions?
Transitional care
“the set of actions designed to ensure coordination and continuity of care between providers and settings of care”
(American Geriatrics Society, 2003)
Transitional care interventions
Care Processese.g.,inpatient & home visits engage caregiverscreate transition planteach medicationstransfer information
Added Staff e.g., APRNs
Outcomese.g., reduced rehospitalization &reduced healthcare cost
Research needs
Describe transitional care for post-acute patients in nursing homes.
Ask
Where do gaps occur? What are outcomes?
Describe how care-team interactions foster or impede transitional care.
Ask
What staff interact? How often do staff interact?
Feasibility study
I searched for the best way to study transitional care as it is provided by existing staff in nursing homes.
Findings 1. Study transitional care over full post-acute care
admission 2. Use Structure-Process-Interactions-Outcomes
Framework 3. Identify gaps and inconsistencies in care
StructureCare
ProcessesOutcomes
Interactions
Transitional Care in a Nursing Home
Model based: (a) Donabedian’s Model of Health Care Quality, (b) Naylor’s Transitional Care Model, (c) Anderson’s Model of Local Interaction Strategies
Structure
Stable facility-level features that support care processes
Examples1. Care-team members2. Procedure for sending records to community provider3. 21 - 28 day length of stay (Medicare reimbursed)
Care processes
Care-team task work aimed at preparing post-acute care patients for discharge and self care at home
Examples1. Develop a transition plan with patients & caregivers2. Teach patients about medications & treatments3. Draft a written care plan4. Transfer medical information to community providers
Interactions
Staff behaviors which promote or impede effective use of transitional care processes
Examples
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.
Outcomes
Direct, patient-centered measurements of the effects of transitional care processes
Examples
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.
Why does any of this matter?
Case Example
86 year old patient with new knee
replacement
- Active family
- Optimistic patient
- Surgical site well-healed
- Good rehabilitation potential
- High risk for falling
Discover gaps in care that we can fix
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.