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.