Transitional Care for Post-Acute Care Patients in Nursing Homes

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Transitional Care for Post-Acute Care Patients
in Nursing Homes

• Mark Toles, MSN, RN

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Acknowledgements

• Duke University School of Nursing
• John A. Hartford Foundation
• Ruth Anderson, PhD, RN, FAAN

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Research goal
Prepare older adults who receive post-acute care
in nursing homes for safe transitions from
nursing homes to home.

• From 1999-2007, the number of post-acute care
  patients in nursing homes increased from 1.4
  million to 1.8 million patients (32).
• Transitional care has rarely been studied for
  these patients.

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Post-acute care patients in nursing homes

• 1. Compared to patients who discharge from
  hospitals to home, they have
• - older age
• - hip fracture, stroke, chronic illness
• - ADL dependence
• 2. Nursing homes may lack skills and resources
  for providing transitional care

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Healthcare transitions after hospitalization
SNF Patients
25 in SNF after 30 days
11 re-hospitalized
53 home
11 home with complications
Coleman et al., 2004
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How do we improve care transitions?

• Transitional care
• the set of actions designed to ensure
  coordination and continuity of care between
  providers and settings of care
• (American Geriatrics Society, 2003)

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Transitional care interventions
Care Processes e.g., inpatient home visits
engage caregivers create transition plan teach
medications transfer information
Added Staff e.g., APRNs
Outcomes e.g., reduced rehospitalization
reduced healthcare cost
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Research needs

• Describe transitional care for post-acute
  patients in nursing homes.
• Ask
• Where do gaps occur?
• What are outcomes?

• Describe how care-team interactions foster or
  impede transitional care.
• Ask
• What staff interact?
• How often do staff interact?

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Feasibility study

• I searched for the best way to study
  transitional care as it is provided by existing
  staff in nursing homes.
• Findings
• 1. Study transitional care over full
  post-acute care admission
• 2. Use Structure-Process-Interactions-Outcomes
  Framework
• 3. Identify gaps and inconsistencies in care

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Transitional Care in a Nursing Home

Structure
Care Processes
Outcomes
Interactions
Model based (a) Donabedians Model of Health
Care Quality, (b) Naylors Transitional Care
Model, (c) Andersons Model of Local Interaction
Strategies
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Structure

• Stable facility-level features that support care
  processes
• Examples
• 1. Care-team members
• 2. Procedure for sending records to community
  provider
• 3. 21 - 28 day length of stay (Medicare
  reimbursed)

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Care processes

• Care-team task work aimed at preparing
  post-acute care patients for discharge and self
  care at home
• Examples
• 1. Develop a transition plan with patients
  caregivers
• 2. Teach patients about medications
  treatments
• 3. Draft a written care plan
• 4. Transfer medical information to community
  providers

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Interactions

• Staff behaviors which promote or impede
  effective use of transitional care processes
• Examples
• 1. A staff member who asks another,
• What does that mean?
• Verification increases information
  exchange.
• 2. Staff members who informally gather
• to discuss a patient.
• Feedback loops improve sensemaking.

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Outcomes

• Direct, patient-centered measurements of the
  effects of transitional care processes
• Examples
• 1. Yes or No was information transferred from
  
• the nursing home to the primary care
  physician?
• 2. Patients verbal descriptions of things they
  have learned to do which facilitate bathing
  at home.

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Why does any of this matter?

• Case Example
• 86 year old patient with new knee replacement
• Active family
• Optimistic patient
• Surgical site well-healed
• Good rehabilitation potential
• - High risk for falling

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Discover gaps in care that we can fix
Structure Excellent, multi-disciplinary team
daily team meeting focused on utilization.
Process OT Patient plan equipment needs
No written planning.
Interactions OT Nursing poorly connected
OT family communication is limited.
Outcome Patient feels prepared for life at
home Error goes home without shower bench.