Variability in Transitional Care Outcomes Across Hospitals Discharging Veterans to Skilled Nursing Facilities

This article describes our recommendation for adapting hospital-based RED (Reengineered Discharge) processes to skilled nursing facilities (SNFs). Using focus groups, the SNFs’ discharge processes were assessed twice additionally, research staff then recorded field notes documenting discussions about facility discharge processes as they related to RED processes. Data were systematically analyzed using thematic analysis to identify recommendations for adapting RED to the SNF setting including (a) rapidly identifying, involving, and preparing family/caregivers to implement a patient focused SNF discharge plan; (b) reconnecting patients quickly to primary care providers; and (c) educating patients at discharge about their target health condition, medications, and impact of changes on other chronic health needs. Limited SNF staff capacity and corporate-level policies limited adoption of some key RED components. Transitional care processes such as RED, developed to avoid discharge problems, can be adapted for SNFs to improve their discharges.

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Implementing transitional care in skilled nursing facilities: Evaluation of a learning collaborative

Geriatric Nursing ◽

10.1016/j.gerinurse.2021.04.010 ◽

2021 ◽

Vol 42 (4) ◽

pp. 863-868

Author(s):

Mark Toles ◽

Alesia Frerichs ◽

Jennifer Leeman

Keyword(s):

Transitional Care ◽

Skilled Nursing Facilities ◽

Nursing Facilities ◽

Learning Collaborative ◽

Skilled Nursing

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Transitional care in skilled nursing facilities: a multiple case study

BMC Health Services Research ◽

10.1186/s12913-016-1427-1 ◽

2016 ◽

Vol 16 (1) ◽

Cited By ~ 15

Author(s):

Mark Toles ◽

Cathleen Colón-Emeric ◽

Mary D. Naylor ◽

Julie Barroso ◽

Ruth A. Anderson

Keyword(s):

Transitional Care ◽

Multiple Case Study ◽

Skilled Nursing Facilities ◽

Nursing Facilities ◽

Skilled Nursing ◽

Multiple Case

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Postacute care outcomes in home health or skilled nursing facilities in patients with a diagnosis of dementia

Health Services Research ◽

10.1111/1475-6773.13855 ◽

2021 ◽

Author(s):

Robert E. Burke ◽

Yao Xu ◽

Ashley Z. Ritter ◽

Rachel M. Werner

Keyword(s):

Home Health ◽

Skilled Nursing Facilities ◽

Nursing Facilities ◽

Skilled Nursing ◽

Diagnosis Of Dementia ◽

Care Outcomes ◽

Postacute Care

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Hospitalist Vs. Non-Hospitalist Care Outcomes and Costs for Medicare Beneficiaries Discharged to Skilled Nursing Facilities in 2012–2014

Journal of General Internal Medicine ◽

10.1007/s11606-019-05459-9 ◽

2019 ◽

Vol 35 (1) ◽

pp. 214-219

Author(s):

Kira L. Ryskina ◽

Yihao Yuan ◽

Daniel Polsky ◽

Rachel M. Werner

Keyword(s):

Skilled Nursing Facilities ◽

Nursing Facilities ◽

Medicare Beneficiaries ◽

Skilled Nursing ◽

Care Outcomes

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Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities

Journal of Applied Gerontology ◽

10.1177/0733464818783689 ◽

2018 ◽

Vol 39 (8) ◽

pp. 855-862 ◽

Cited By ~ 1

Author(s):

Mark Toles ◽

Jennifer Leeman ◽

Cathleen Colón-Emeric ◽

Laura C. Hanson

Keyword(s):

Transitional Care ◽

Retrospective Chart Review ◽

Skilled Nursing Facilities ◽

Care Plan ◽

Nursing Facilities ◽

Skilled Nursing ◽

Transition Care ◽

Intervention Protocol ◽

Implementation Tool ◽

The Impact

Prior studies have not described strategies for implementing transitional care in skilled nursing facilities (SNFs). As part of the Connect-Home study, we pilot tested the Transition Plan of Care (TPOC) template, an implementation tool that SNF staff used to deliver transitional care. A retrospective chart review was used to describe the impact of the TPOC template on three implementation outcomes: reach to patients, staff adoption of the template, and staff fidelity to the intervention protocol for transition care planning. The template reached 100% of eligible patients ( N = 68). Adoption was high, with documentation by four disciplines in 90.6% of patient records ( N = 61). Fidelity to the intervention protocol was moderately high, with 73% of documentation that was concordant with the protocol. Our findings suggest an electronic medical record (EMR)-based implementation tool may increase the ability of staff to prepare older adults and their caregivers for self-care at home. Further research is needed to test the efficacy of the protocol on patient outcomes after transitions from SNF to home.

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