scholarly journals Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities

2018 ◽  
Vol 39 (8) ◽  
pp. 855-862 ◽  
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.

scholarly journals Transitional care of older adults in skilled nursing facilities: A systematic review

2016 ◽  
Vol 37 (4) ◽  
pp. 296-301 ◽  
Author(s):  
Mark Toles ◽  
Cathleen Colón-Emeric ◽  
Josephine Asafu-Adjei ◽  
Elizabeth Moreton ◽  
Laura C. Hanson
Keyword(s):  
Systematic Review ◽  
Older Adults ◽  
Transitional Care ◽  
Skilled Nursing Facilities ◽  
Nursing Facilities ◽  
Skilled Nursing

scholarly journals Difficult Discharges to Skilled Nursing Facilities Attributed to Multiple Sclerosis Medications: An Observational Study

2019 ◽  
Vol 10 (2) ◽  
pp. 82-87
Author(s):  
Kathleen C. Munger ◽  
Benjamin P. George ◽  
Lawrence M. Samkoff ◽  
Jessica F. Robb
Keyword(s):  
Multiple Sclerosis ◽  
Medical Center ◽  
Academic Medical Center ◽  
Retrospective Chart Review ◽  
Skilled Nursing Facilities ◽  
Nursing Facilities ◽  
Skilled Nursing ◽  
Medication Costs ◽  
Medication Discontinuation ◽  
Academic Medical

Background: The costs of multiple sclerosis (MS) disease-modifying therapies (DMTs) and certain symptomatic treatments (ie, dalfampridine [DFP]) are high. Consolidated billing models require that medication costs be covered by skilled nursing facilities (SNFs) after hospitalization. As a result, patients may experience suboptimal discharge, off of medication or without rehabilitation. Methods: To characterize the frequency with which MS pharmaceutical costs lead to suboptimal discharge, we performed a retrospective chart review of admissions to a large academic medical center from January 2013 to December 2017 among patients with MS on DMT and/or DFP with SNF rehabilitation recommendations. We quantified the burden of suboptimal discharge due to medication discontinuation, limited medication supplies, or forgone rehabilitation. Results: Among 169 admissions of patients with MS with discharge recommendations for SNF rehabilitation, there were 57 (33.7%) admissions across 49 patients with MS on DMT/DFP. Overall, 39 (68%) of 57 admissions (71% of patients) experienced a suboptimal discharge. Overall, 29 (65%) discontinued DMT/DFP, 9 (16%) took their remaining home supply of medications during rehabilitation (including 5 admissions also affected by a discontinuation), and 6 (11%) were discharged home to remain on DMT. Among those discharged to rehabilitation, discharge to a hospital-owned SNF was associated with a routine discharge with no lapse in medication (n = 11/15 vs 7/36, P < .001). Conclusions: High costs of MS medications in conjunction with SNF consolidated payment models result in misaligned incentives and often lead to medication discontinuation or other suboptimal discharge for patients with MS.

Decreasing Readmissions Through Transitional Care from Skilled Nursing Facilities to Home

2016 ◽  
Vol 17 (3) ◽  
pp. B14
Author(s):  
Kristin Brockway ◽  
David Thimons ◽  
Kristin Brockway ◽  
Jay Hartle ◽  
Lisa Dusch ◽  
...  
Keyword(s):  
Transitional Care ◽  
Skilled Nursing Facilities ◽  
Nursing Facilities ◽  
Skilled Nursing

Implementation of the FIRM (Foley Insertion, Removal, and Maintenance) protocol in skilled nursing facilities

2014 ◽  
Vol 1 ◽  
pp. 10-12
Author(s):  
Murthy Gokula ◽  
Phyllis M Gaspar
Keyword(s):  
Health Care Providers ◽  
Care Management ◽  
Chart Review ◽  
Retrospective Chart Review ◽  
Skilled Nursing Facilities ◽  
Evidence Based ◽  
Nursing Facilities ◽  
Care Providers ◽  
Urinary Catheters ◽  
Skilled Nursing

The purpose of this study was to determine the feasibility and outcomes of the implementation of an evidence based protocol, Foley Insertion Removal and Maintenance (FIRM) for the use and care management of indwelling urinary catheters (IUC) for skilled nursing facilities (SNF). The protocol consists of an order set for insertion, maintenance, and removal complemented with an education program for health care providers of SNF.  It was implemented over a six month period in two SNF.  Prospective chart review following implementation revealed an 11.3 rate of IUC per month.  Documentation of the indication for placement of an IUC was 98.5%.  Retrospective chart review revealed a lower use of IUC prior to implementation of the protocol but the lack of documentation of orders for IUC artificially reduced the rate.  FIRM protocol is advocated as a facility policy with a nurse champion to facilitate implementation and surveillance.

QI Initiative to Improve Transitional Care Processes Regarding Discharge from Skilled Nursing facilities

2020 ◽  
Vol 21 (3) ◽  
pp. B25
Author(s):  
Mamata Yanamadala ◽  
Mamata Yanamadala ◽  
Heather Jacobson ◽  
Serena Wong ◽  
Heidi White
Keyword(s):  
Transitional Care ◽  
Skilled Nursing Facilities ◽  
Nursing Facilities ◽  
Skilled Nursing ◽  
Care Processes

scholarly journals Adapting Project RED to Skilled Nursing Facilities

2018 ◽  
Vol 29 (3) ◽  
pp. 149-156 ◽  
Author(s):  
Lori L. Popejoy ◽  
Amy A. Vogelsmeier ◽  
Bonnie J. Wakefield ◽  
Colleen M. Galambos ◽  
Alexandria M. Lewis ◽  
...  
Keyword(s):  
Transitional Care ◽  
Primary Care Providers ◽  
Health Condition ◽  
Skilled Nursing Facilities ◽  
Nursing Facilities ◽  
Care Providers ◽  
Skilled Nursing ◽  
Discharge Plan ◽  
Care Processes ◽  
Field Notes

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.

scholarly journals 2056. Retrospective Analysis of Intravenous Vancomycin Outcomes in Patients Discharged to Skilled Nursing Facilities

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S693-S693
Author(s):  
Heather D Gibson ◽  
Gretchen S Arnoczy ◽  
Andrew Kessell ◽  
Jaspaul S Jawanda
Keyword(s):  
Adverse Events ◽  
Retrospective Chart Review ◽  
Skilled Nursing Facilities ◽  
Nursing Facilities ◽  
Skilled Nursing ◽  
Therapy Assessment ◽  
Increased Risk ◽  
Vancomycin Trough ◽  
Provider Outcomes ◽  
Significant Opportunity

Abstract Background Patients treated with intravenous (IV) vancomycin at skilled nursing facilities (SNFs) are at increased risk for adverse events. Methods Single-center, retrospective chart review to assess specific outcomes of patients receiving IV vancomycin discharged to an SNF from a single institution under the care of infectious diseases (ID) physicians. Population included all patients under the care of an ID provider between November 1, 2017 and October 31, 2018 with GFR > 30 who were discharged to an SNF on IV vancomycin for a minimum of 2 weeks. Patients with chronic kidney disease and patients younger than 18 years old were excluded. It was intended that all patients have weekly labs, including vancomycin troughs, communicated to the ID provider. Outcomes evaluated included complications related to vancomycin therapy, assessment of appropriate trough timing and sub-therapeutic troughs (defined as a trough less than 10), and assessment of communication to the prescribing physician. Complications were defined as vancomycin trough greater than 30, increase in serum creatinine greater than 0.5 above baseline, documented adverse events related to vancomycin, or hospital readmission during antibiotic therapy. Results 25 patients who met inclusion criteria were admitted to 14 different SNFs. Osteomyelitis was the most common indication and MRSA was the most commonly isolated organism. 13 of 25 patients experienced the predefined complications; 5 of 25 patients had at least one trough value greater than 30. 13 of 25 patients had troughs drawn at inappropriate times in relation to doses and 15 of 25 patients had either absent or incomplete labs communicated to the prescriber. 4 of 25 patients had at least one trough value less than 10. Only 2 of 25 patients assessed had no complications, troughs appropriately drawn, and lab values communicated to the prescriber. Conclusion Patients discharged to SNFs on vancomycin had high rates of complications, low rates of appropriate laboratory monitoring, and poor communication between SNFs and the prescribing ID physician. Vancomycin administration at an SNF warrants careful monitoring for patient safety and demonstrates an area with significant opportunity for improvement. Disclosures All authors: No reported disclosures.

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