Transitional care following a skilled nursing facility stay: Utilization of nurse practitioners to reduce readmissions in high risk older adults

2021 ◽  
Author(s):  
Tiffany Rose ◽  
Karen Frith ◽  
Rachel Zimmer
Keyword(s):  
Older Adults ◽  
High Risk ◽  
Nurse Practitioners ◽  
Transitional Care ◽  
Skilled Nursing Facility ◽  
Nursing Facility ◽  
Skilled Nursing

scholarly journals 1206. Association of Aging, Frailty and Place of Residence with Skin, Oral and Gut Microbiome Characteristics and Pathogenicity Reservoirs

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S625-S625
Author(s):  
Peter J Larson ◽  
Julia Oh ◽  
Julie Robison ◽  
James Grady ◽  
George Kuchel
Keyword(s):  
Older Adults ◽  
Gut Microbiome ◽  
Skilled Nursing Facility ◽  
Antibiotic Resistance Genes ◽  
Community Dwelling ◽  
Colonization Resistance ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Cutibacterium Acnes ◽  
Control And Prevention

Abstract Background Despite their elevated risk for morbidity and mortality from infections, the microbiota of older adults remain understudied. While colonization resistance from resident microflora is a promising means to prevent infections, little is known about pathogenicity reservoirs and colonization resistance in this vulnerable population. Here we study the skin, oral, and gut microbiome dynamics of older adults in both community and Skilled Nursing Facility (SNF) settings, investigating relationships between age, frailty, environment, microbiota, and pathogenicity reservoirs. Methods We conducted a longitudinal metagenome survey of 47 adults age 65+ years of age; 22 residents of 3 different SNFs and 25 community dwelling individuals. We performed metagenomic whole genome shotgun sequencing on stool, oral, and skin samples from 8 sites, 1421 total. To correlate clinical and behavioral variables, we measured frailty, collected medical records, and interviewed participants on diet and lifestyle. We also draw comparisons with previous younger cohorts. Results • Compared to younger adults, the skin microbiota of older adults was characterized by ◦ High heterogeneity ◦ Decreased stability over time, suggesting increased susceptibility to colonization and pathogenicity ◦ Compositional differences including significantly lower levels of Cutibacterium acnes, with reciprocal increases in Staphylococci, Corynebacteria, and Malassezia • In older adults, Frailty (Rockwood) was found to have linear correlation with relative abundance of species relevant to infection risk including acnes, staphylococci, streptococci, E. coli, Akkermansia mucinophila, and Enterococcus faecalis. • The skin, oral, and gut microbiota of SNF residents had substantially elevated virulence factor and antibiotic resistance genes. Conclusion To the best of our knowledge, this is largest report to date of the skin metagenome in older adults. We demonstrate distinct and significant differences between cohorts with clinically relevant implications. We believe these results may inform infection control and prevention by increasing our understanding of colonization resistance and pathogenicity reservoirs, as well as advance our knowledge of the relationship between aging, the microbiome, and infections. Disclosures All Authors: No reported disclosures

Progressive Mobility As a Team Effort in Transitional Care

2015 ◽  
Vol 35 (3) ◽  
pp. 62-68 ◽  
Author(s):  
Margaret M. Ecklund ◽  
Jill W. Bloss
Keyword(s):  
Hospital Readmission ◽  
Transitional Care ◽  
Interdisciplinary Collaboration ◽  
Skilled Nursing Facility ◽  
Care Program ◽  
Care Needs ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Core Culture ◽  
The Continuum

With changing health care, progressive care nurses are working in diverse practice settings to meet patient care needs. Progressive care is practiced along the continuum from the intensive care unit to home. The benefits of early progressive mobility are examined with a focus on the interdisciplinary collaboration for care in a transitional care program of a skilled nursing facility. The program’s goals are improved functional status, self-care management, and home discharge with reduced risk for hospital readmission. The core culture of the program is interdisciplinary collaboration and team partnership for care of patients and their families.

scholarly journals Connect-Home: Transitional Care of Skilled Nursing Facility Patients and their Caregivers

2017 ◽  
Vol 65 (10) ◽  
pp. 2322-2328 ◽  
Author(s):  
Mark Toles ◽  
Cathleen Colón-Emeric ◽  
Mary D. Naylor ◽  
Josephine Asafu-Adjei ◽  
Laura C. Hanson
Keyword(s):  
Transitional Care ◽  
Skilled Nursing Facility ◽  
Nursing Facility ◽  
Skilled Nursing

scholarly journals Clinical Courses and Characteristics of Residents During a SARS-CoV-2 Outbreak at a Central Indiana Skilled Nursing Facility

2020 ◽  
Vol 3 ◽  
Author(s):  
Lauren Albert ◽  
Kristi Lieb ◽  
Laramie Mack ◽  
Kathleen Unroe
Keyword(s):  
Older Adults ◽  
Case Reports ◽  
Skilled Nursing Facility ◽  
Nursing Facilities ◽  
Retrospective Case ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Increased Risk ◽  
Symptom Load ◽  
Retrospective Case Study

Background/Objective: Older adults such as skilled nursing facility residents have increased risk of serious SARS-CoV-2 infection and comprise a large proportion of the COVID-19 pandemic’s deceased—the US Centers for Medicare & Medicaid Services report 232,831 cases and 38,518 resident deaths to date. Recent case reports reveal, as in other diseases, older adults may experience atypical symptomology, complicating identification of ill residents and efforts to slow transmission. While a few facility outbreaks have been characterized epidemiologically, little research exists regarding clinical timelines and trajectories which residents experience during COVID-19 illness.   Methods: From May 9, 2020-June 1, 2020, daily notes on each COVID-19 positive resident’s status (n = 69) were taken by the medical director of a central Indiana nursing facility. Combined with a retrospective resident chart review of this same period, these notes were examined for COVID-19 infection symptoms and illness timelines to descriptively categorize a number of common illness trajectories and symptoms seen in residents with SARS-CoV-2 infection.  Results: Residents fit four descriptive clinical timelines: concurrent symptom load with quick death (Avg 5.6 days) (n = 5), accumulating symptom load with gradual decline (Avg. 13.9 days) (n = 9), prolonged active symptom load with periods of stabilization and symptom reoccurrence (n = 42), and asymptomatic or atypical symptom load (n = 12). Most common symptoms were fever, hypoxia, anorexia, and fatigue/malaise. Of the 14 residents who died (20.3% of infected), 8 died in the facility and 6 died in the hospital.  Conclusion and Implications: This retrospective case study adds to literature describing the presentation and symptomology of SARS-CoV-2 infection in residents of skilled nursing facilities and aids efforts to evaluate resident presentation, prognosis, and disease course. Robust descriptions of expected clinical courses may support realistic expectations of disease progression for residents and their family members experiencing future outbreaks.

Impact of Comprehensive Nurse-Managed Transitional Care

2001 ◽  
Vol 10 (3) ◽  
pp. 295-313 ◽  
Author(s):  
Ruth M. Tappen ◽  
Rosemary F. Hall ◽  
Susan L. Folden
Keyword(s):  
Daily Living ◽  
Transitional Care ◽  
Comparison Group ◽  
Skilled Nursing Facility ◽  
Design Data ◽  
Nursing Facility ◽  
Care Environment ◽  
Skilled Nursing ◽  
Quasi Experimental

The purpose of this study was to test the effectiveness of nurse-managed transitional care on the quality of care and functional ability of individuals following discharge from subacute units. Registered nurses employed on subacute units in a skilled nursing facility provided the nurse-managed transitional care. Using a quasi-experimental design, data were collected on admission to the subacute unit, at the time of discharge, 1 week following discharge, and 3 months following discharge on 242 treatment and comparison participants. The treatment group participants' overall function and quality of the care environment were significantly higher than the comparison group at 1 week and 3 months following discharge. Participants did not differ significantly on basic activities of daily living or number of readmissions.

scholarly journals Impaired Arousal in Older Adults Is Associated With Prolonged Hospital Stay and Discharge to Skilled Nursing Facility

2015 ◽  
Vol 16 (7) ◽  
pp. 586-589 ◽  
Author(s):  
Andrea M. Yevchak ◽  
Jin Ho Han ◽  
Kelly Doherty ◽  
Elizabeth G. Archambault ◽  
Brittany Kelly ◽  
...  
Keyword(s):  
Older Adults ◽  
Hospital Stay ◽  
Skilled Nursing Facility ◽  
Prolonged Hospital Stay ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Prolonged Hospital

scholarly journals Transitional Care Outcomes in Veterans Receiving Post‐Acute Care in a Skilled Nursing Facility

2019 ◽  
Vol 67 (9) ◽  
pp. 1820-1826 ◽  
Author(s):  
Robert E. Burke ◽  
Anne Canamucio ◽  
Thomas J. Glorioso ◽  
Anna E. Barón ◽  
Kira L. Ryskina
Keyword(s):  
Acute Care ◽  
Transitional Care ◽  
Skilled Nursing Facility ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Care Outcomes ◽  
Post Acute Care

scholarly journals TRANSITIONAL CARE OUTCOMES IN VETERANS RECEIVING POST-ACUTE CARE IN A SKILLED NURSING FACILITY

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S732-S732
Author(s):  
Robert Burke ◽  
Anne Canamucio ◽  
Thomas Glorioso ◽  
Anna Baron ◽  
Kira Ryskina
Keyword(s):  
Acute Care ◽  
Transitional Care ◽  
Adverse Outcome ◽  
Skilled Nursing Facility ◽  
Adverse Outcomes ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Episodes Of Care ◽  
Va Hospitals ◽  
Post Acute Care

Abstract More than 200,000 Veterans transition between hospital and skilled nursing facility (SNF) annually. Capturing outcomes of these transitions has been challenging because older adult Veterans receive care at VA and non-VA hospitals, and four different kinds of SNFs: VA-owned and -operated Community Living Centers (CLCs), VA-contracted community nursing homes (CNHs), State Veterans Homes (SVHs), and non-VA community SNFs. We used a novel data source which concatenates VA, Medicare, and Medicaid data into longitudinal episodes of care for Veterans, to calculate the rate of adverse outcomes associated with the transition from hospital to SNF in all enrolled Veterans age 65 and older undergoing this transition 2012-2014. The composite primary outcome included Emergency Department (ED) visits, rehospitalizations, and mortality (not in the context of hospice) within 7 days of hospital discharge to SNF. We used multivariable logistic regression to adjust for Veteran and hospital characteristics and hospital random effects. In the 388,339 Veterans discharged from 1502 hospitals in our sample, we found more than 4 in 5 Veteran transitions (81.7%) occurred entirely outside the VA system. The overall 7-day outcome rate was 10.7%. After adjustment, VA hospitals had lower adverse outcome rates than non-VA hospitals (OR 0.80, 95% CI 0.74-0.86). VA hospital-CLC transitions had the lowest adverse outcome rates; in comparison, non-VA hospital-CNH (OR 2.51, 95% CI 2.09-3.02) and non-VA hospital-CLC (OR 2.25, 95% CI 1.81-2.79) had the highest rates. These findings raise important questions about the VA’s role as a major provider and payer of post-acute care in SNF.

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