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
Prepare older adults who receive post-acute care in nursing
homes for safe transitions from nursing homes to home.
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.
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-hospitalized
53% 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
Added Staff
Care Processes
Outcomes
e.g.,
APRNs
e.g.,
inpatient & home visits
engage caregivers
create transition plan
teach medications
transfer information
e.g.,
reduced
rehospitalization
&
reduced healthcare
cost
Research needs
Describe transitional care
for post-acute patients in
nursing homes.
Describe how care-team
interactions foster or
impede transitional care.
Ask
Where do gaps occur?
What are outcomes?
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
Transitional Care in a Nursing Home
Structure
Care
Processes
Outcomes
Interactions
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
Examples
1. Care-team members
2. Procedure for sending records to community provider
3. 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
Examples
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
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.