Transitional Care Management in patients discharging from Skilled Nursing facility: Combating Rehospitalization and Bridging the Gaps in Care

2018 ◽  
Vol 19 (3) ◽  
pp. B30
Author(s):  
Chandan Cheema ◽  
R. Brar ◽  
A. Narwan ◽  
C. Cheema
Keyword(s):  
Care Management ◽  
Transitional Care ◽  
Skilled Nursing Facility ◽  
Nursing Facility ◽  
Skilled Nursing

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

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 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.

scholarly journals Staff Interaction Strategies That Optimize Delivery of Transitional Care in a Skilled Nursing Facility

2012 ◽  
Vol 35 (4) ◽  
pp. 334-344 ◽  
Author(s):  
Mark Toles ◽  
Julie Barroso ◽  
Cathleen Colón-Emeric ◽  
Kirsten Corazzini ◽  
Eleanor McConnell ◽  
...  
Keyword(s):  
Transitional Care ◽  
Skilled Nursing Facility ◽  
Nursing Facility ◽  
Skilled Nursing

Care Management and the Transition of Older Adults From a Skilled Nursing Facility Back Into the Community

2011 ◽  
Vol 12 (2) ◽  
pp. 54-59 ◽  
Author(s):  
Adam G. Golden ◽  
Shanique Martin ◽  
Melanie da Silva ◽  
Bernard A. Roos
Keyword(s):  
Older Adults ◽  
Health Care ◽  
Nursing Care ◽  
Care Management ◽  
Skilled Nursing Facility ◽  
Skilled Nursing Facilities ◽  
Nursing Facilities ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Management Interventions

After hospitalization, many older adults require skilled nursing care. Although some patients receive services at home, others are admitted to a skilled nursing facility. In the current fragmented health care system, hospitals are financially incentivized to discharge frail older adults to a facility for postacute care as soon as possible. Similarly, many skilled nursing facilities are incentivized to extend the posthospitalization period of care and to transition the patient to custodial nursing home care. The resulting overuse of institution-based skilled nursing care may be associated with various adverse medical, social, and financial consequences. Care management interventions for more efficient and effective skilled nursing facility use must consider the determinants involved in the decisions to admit and maintain patients in skilled nursing facilities. As we await health care reform efforts that will address these barriers, opportunities already exist for care managers to improve the current postacute transition processes.

Measuring the Impact of Medication-Related Interventions on 30-Day Readmission Rates in a Skilled Nursing Facility

2018 ◽  
Vol 33 (3) ◽  
pp. 306-313
Author(s):  
Priya B. Amin ◽  
Chad D. Bradford ◽  
Albert L. Rizos ◽  
Bijal M. Shah
Keyword(s):  
Transitional Care ◽  
Skilled Nursing Facility ◽  
Intervention Group ◽  
Care Team ◽  
Control Group ◽  
Readmission Rates ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Transitional Services ◽  
The Impact

Background: There is a lack of published literature that measures the impact of transitional care pharmacist (TCP) medication-related interventions within the skilled nursing facility (SNF) setting. Objectives To evaluate the impact of TCP medication-related interventions on 30-day hospital readmissions among SNF patients compared to current standard of care. Methods: This was a retrospective pilot study. All patients included in the study were discharged from an inpatient facility to a SNF. The control group received transitional services from a care team with no pharmacist. The intervention group received transitional services from a care team plus a pharmacist. Results: The 30-day readmission rates in the intervention group were 14 (12%)/116 compared to the control group, 19 (16%)/116; however, the difference was not statistically significant ( P = .35). The median time to readmission was statistically significantly longer in the intervention group, 17.5 days, compared to the control group, 10 days ( P = .02). One hundred seventy-four medication-related interventions were performed in the intervention group during the study period. Conclusion: This study demonstrates that TCP interventions in an SNF are associated with a significant delay in readmission. A continuation of the pilot program may show a role in reducing all-cause 30-day readmission and ED visit rates.

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