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.

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 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.

Perceived Benefits, Barriers, and Drivers of Telemedicine From the Perspective of Skilled Nursing Facility Administrative Staff Stakeholders

2016 ◽  
Vol 37 (1) ◽  
pp. 110-120 ◽  
Author(s):  
Julia Driessen ◽  
Nicholas G. Castle ◽  
Steven M. Handler
Keyword(s):  
Research Policy ◽  
Skilled Nursing Facility ◽  
Evidence Base ◽  
Administrative Staff ◽  
Joint Research ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Avoidable Hospitalizations ◽  
Unique Approach

Potentially avoidable hospitalizations (PAHs) of skilled nursing facility (SNF) patients are common and costly. Telemedicine represents a unique approach to manage and potentially reduce PAHs in SNFs, having been used in a variety of settings to improve coordination of care and enhance access to providers. Nonetheless, broad implementation and use of telemedicine lags in SNFs relative to other health care settings. To understand why, we surveyed SNF administrative staff attending a 1-day telemedicine summit. Participants saw the highest value of telemedicine in improving the quality of care and reducing readmissions. They identified hospital and managed care telemedicine requirements as primary drivers of adoption. The most significant barrier to adoption was the initial investment required. A joint research-policy effort to improve the evidence base around telemedicine in SNFs and introduce incentives may improve adoption and continued use of telemedicine in this setting.

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