Transitional Care for Post-Acute Care Patients in Nursing Homes Mark Toles, MSN, RN

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

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

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

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

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)

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

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?

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

Structure Care Processes Outcomes Interactions Transitional Care in a Nursing Home Model based: (a) Donabedian’s Model of Health Care Quality, (b) Naylor’s Transitional Care Model, (c) Anderson’s Model of Local Interaction Strategies

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

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

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.

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.

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

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.