Geriatric Resident Rotation Independent Learning Activity in Care Transitions
Objectives:
1. Identify the discharge summary as a key component of communication between the hospital
and the post-acute care setting
2. Identify types of information which should be included in a hospital discharge summary or
transfer form from hospital to skilled nursing facility to optimize continuation of care
3. Perform a complete medication reconciliation between home to hospital to skilled nursing
facility and identify areas of potential medication error
4. Identify health systems/processes of care errors and barriers in the transition from hospital to
post-acute care setting
5. Understand the steps and processes in care transition from hospital to post-acute care setting to
identify a potential intervention to improve the quality of the care transition
Learner Instructions: **Each person will need to fill out and turn in their own forms to get credit for
the activity. DO NOT put patient identifier information on the forms (like name, initials, DOB). It is
only OK to put patient age, sex, and race on the forms.**
Reviewing the Discharge Summary:
1. Arrive at Fair Haven Nursing Home (1424 Montclair Road, phone: 205-956-4150) at 1:30pm.
Turn left onto Cooper Hill Road, just past Fair Haven and before the BB&T Bank. Park in the lot
on the Left. Enter the nursing home by the fountain/circle drive. Ask the front desk to show
you how to get to East Wing or 5-North (you’ll need a door code to get in and out of the unit, so
write it down!).
2. Arrive on East Wing or 5-North. Find the chart for your patient. The chart should either be on
the rack or on the desk. If you can’t find it, ask one of the staff to help you find it.
3. In the nursing home chart, find the admission tab. Under this tab, you should see the hospital
discharge summary and possibly a hospital admission history and physical.
4. Read through the discharge summary and fill out the “Discharge Summary Chart Review Tool.”
Feel free to write any additional comments about the quality of this discharge summary as a
communication tool at the bottom of the page.
Reconciling the Medications:
1. Using only the discharge summary, the medications on the transfer form, and the hospital
admission history and physical (if available), make 2 lists at the top of the “Medication
Reconciliation Chart Review Check List:” (1) home medications prior to admission, and (2)
discharge medications. If the H&P is not available and there are no home medications listed on
the discharge summary, during your interview of the patient, ask them what their home
medicines were. If the patient is unable to provide this information, you can call their primary
contact person listed on the face sheet in the front of their chart.
2. Fill out the “Medication Reconciliation Chart Review Check List” for your patient.
Patient Evaluation and Plan Development:
1. Prepare for your patient evaluation by noting any additional information you need from the
patient/family or concerns you have as the provider caring for this patient who was just
discharged from the hospital.
2. Find your patient in his/her room. If the patient is not in the room, ask the nursing staff where
they are—they may be in therapy or the dining room. You may interview them in those
locations. The staff can show you how to get there.
3. If your patient is unavailable (ex: out of the building at doctor’s appointment), you may move on
to the “Evaluation of Transition of Care Process” step below.
4. Focus your patient history and evaluation on:
a. baseline and current functional status (ADLs, IADLs)
b. prior living situation and available caregiver support
c. presence and status of geriatric syndromes (delirium, depression, dementia,
incontinence, falls, etc)
d. home medications (if you need to obtain these or need to clarify)
e. patient’s functional or medical goals for their time in rehab
Note: If the patient is unable to provide the information in items a-e above or you need to
confirm the information they provide, you can also obtain this history from their primary
contact.
The CNAs, nurses, therapists, and social worker can also provide information on the current
functional status and prior living situation and support. Feel free to ask these other team
members for their input if you’re patient is unable to provide this. The therapy gym is next
to 5-North. The social worker’s office is on the balcony of the 2nd floor, just out the door
from East Wing.
5. Do a focused physical exam of your patient, focusing on areas of clinical concern (ex: deliriumconfusion assessment method, cognitive impairment-SLUMS or mini-cog. SLUMS exam sheets
are in the physician office near 5-North). If you need help during the exam (ex: positioning the
patient) ask one of the CNAs or the nurse to help you. If you need the patient to walk or stand
to perform an evaluation, first ask the nurse or CNA if the patient is safe to do so. If they are
safe, but you need physical assistance, ask the CNAs or nurse to help you.
a. If at any time, you are concerned about an acute medical condition or acute change in
condition of the patient, alert the nurse who can then contact the patient’s physician.
6. After your evaluation of the patient, write up a brief assessment and plan for the medical
problems as well as functional and psychosocial issues on the “Initial Post-Acute Care Visit Plan”
form.
7. Read through the discharge summary again. Now that you have evaluated the patient, make a
list of additional information at the top of your assessment and plan form that you would like to
have had on the discharge summary that would have helped you develop a clear plan for this
patient.
Evaluation of Transition of Care Process:
1. Find the head nurse on your patient’s unit.
2. Ask the nurse the following questions to gain their perspective on the transition from hospital to
SNF:
a. Did the nurse at the hospital communicate verbally with you or your staff about the
patient?
i. Did the nurse at the hospital provide you enough information to help you care
for the patient on admission? Is there other information that you needed to
help you prepare for the patient?
ii. Are there medications or supplies that were needed for the patient that you did
not know about or have when the patient arrived?
iii. Are there nursing needs that the patient has that you were not prepared for or
aware of?
b. What medication list do you usually use for the initial orders for new patients?
i. Did you find errors or discrepancies on the medication list?
ii. How do medication errors or discrepancies affect the care the patients receive?
c. What concerns do you have about the quality of this patient’s transition from hospital to
skill nursing facility?
d. What are some of the barriers and challenges you encounter in general in the patient
transition from hospital to skilled nursing facility?
Care Transition Improvement Ideas:
1. On the back of the “Initial Post-Acute Care Plan” form, make a short list of barriers/errors that
you found and/or that the nurse reported in the transition of care of this patient from hospital
to SNF. At the end of the month, these ideas will be discussed with the whole learning group.
2. Please bring all of your completed forms to the end of the month group discussion. You will
need your forms to present your patient to the group and to get credit for the activity.
Leaving Fair Haven: You will need the door code to exit the unit.