Background
Guiding models
Organizational Structure: Three organizational supports in SNFs that facilitate delivery of transitional care services [18]. | |
Structure | Definition |
Staff knowledge | Professional staff members (e.g., physicians, nurses, rehabilitation therapists and social workers) are (a) available to patients and family caregivers and (b) skilled in delivering transitional care. |
Care routines | Predictable schedules that staff members use to deliver transitional care, including team meetings focused on patient and caregiver needs, family and patients meetings, and cycles of care delivery and assessment to monitor outcomes. |
Tools | Templates and information technology that staff use to document transitional care services and for create individualized patient and caregiver written instructions. |
Interaction | Definition |
Connect | Staff members are (a) approachable for building relationships with patients and family caregivers; (b) pitch-in to help each other, patients and family caregivers; (c) recognize each other as care team members. |
Exchange information | Staff members (a) listen to each other, patients, and family caregivers; (b) relay and verify the accuracy of new information; (c) communicate in pairs and larger groups of care-team members. |
Solve problems | Staff members ask questions and give feedback to develop new information or understanding. Groups of care-team members participate in conversations to solve emerging problems in care. |
Process | Definition |
Assess | Evaluates patient and caregiver preferences, strengths and needs related to health care for ensuring patients’ self-care ability and safety at home. |
Plan | Creates multidisciplinary goals and measures to deliver transitional care based on assessments of patient and caregiver preferences, strengths and needs. |
Engage | Collaborates with patients and caregivers to ensure that (a) implemented plans are congruent with their preferences and goals and (b) patients feel motivated to implement transition plans. |
Reconcile medication | Verifies a correct medication list, using medications lists from home, hospital and SNF stays, and orders for planned care at home. Inaccuracies and errors of omission or commission are corrected. |
Refer | Schedules and confirms the feasibility of services planned for care at home, e.g., MD appointments, home care, social services, rehabilitation, and tests/procedures. |
Educate | Ensures that patients and caregivers have a written record and clear understanding of (a) the transition plan; (b) the name, purpose, dosage, administration, and side effects of medications, and (c) how to recognize and respond to warning signs changes in health or medical conditions. |
Transfer | Sends timely and accurate summaries of SNF care and plans for the transition home to community providers of care. |
Follow-up | Provides follow-up phone calls or home visits to promote patients’ and family caregivers’ implementation of transition plans at home. |
Methods
Ethics and consent
Setting and participant sample
Case | 1 | 2 | 3 |
---|---|---|---|
SNF Characteristics | |||
Ownership | Private | Chain | Chain |
Profit status | For profit | For profit | For profit |
Size (bed count) | 100 - 150 | <100 | >150 |
% Medicaid | <20 % | >50 % | >50 % |
Nursing Home Compare | 5 stars | 4 stars | 1 star |
Patients Characteristics | |||
Patient age/gender | 75 yrs./female | 78 yrs./female | 69 yrs./female |
Patient length of stay | 28 days | 20 days | 20 days |
Patient medical condition | Cervical fusion and multiple health conditions | Kidney failure and multiple health conditions | Lumbar fusion and multiple health conditions |
Primary Caregiver Characteristics | |||
Enrolled | None Available | Yes | Yes |
Relationship to patient | n/a | Daughter | Daughter |
SNF Staff Characteristics | |||
Staff care-team membersa | LPN, MD, SW, NP, OT, PT, ARN | SW, RN, LPN, MD, OT, PT, RD, CC | SW, LPN, NP, RN, MD, OT, PT |
Managers and Department Heads | 8 enrolled | 9 enrolled | 8 enrolled |
Data collection
Subject or Data Source | Week | |||||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1-3 | 4 | 5-7 | 8-9 | |||||||||||||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | ||||
Interviews and Observations | ||||||||||||||||||||||
Patient | r | c | f | o | o | o | f | o | o | o | o | f | ||||||||||
Caregiver | r | c | f | o | o | f | ||||||||||||||||
OT | r | c | f | o | o | o | o | o | f | |||||||||||||
PT | r | c | f | o | o | o | o | f | ||||||||||||||
SW | c, f | r | c | f | o | o | o | f | ||||||||||||||
LPN | r | c | o | o | o | o | f | |||||||||||||||
NP | c, f | r | c | o | o | o | f | |||||||||||||||
MD | r | c | o | o | f | |||||||||||||||||
RN | r | c | f | o | o | f | o | |||||||||||||||
Other | c, f | c | o | o | f | |||||||||||||||||
Other data sources | ||||||||||||||||||||||
Meetings | o | o | o | o | o | o | o | o | o | o | o | o | o | o | o | o | ||||||
Chart | d | d | d | d | d | d | d | d | d | d | d | d | d | d | d | d | d | d | d | |||
Document | d | d | d | d | d | d | d | d | d | d |
Semi-structured interviews
Observations and document reviews
Data analysis
Results
Theme 1: Organizational support and staff members who delivered transitional care services
“My job is to…negotiate between the rehabilitation time under Medicare, what the patient is looking for, what the family is looking for, and to figure-out how to get everybody on the same page.”
“They have been watching my Dilantin levels here and I am told they have adjusted that medicine and that my levels will return to normal. My doctor knows about that too.” (Patient)“I have been using OxyContin for pain but that is changing too. I am starting Tylenol now and I will take that when I get home as well.” (Patient)
“It’s a way to care for those people that are going to stay with us…we would transition them from one of our units to another.” (Nurse)
“I wish I knew more about what to look for if [patient] started getting signs of getting sick or her health started failing again; what to do and who to call on for that.” (Family Caregiver)“I know they worked with my mother but they should bring a family member in too and teach them what we should be able to do…to help this person to maneuver around like they did in the facility.” (Family Caregiver)
“We learned that it really does help to have the family meeting early in the admission because, if we don’t, there is not enough time to get the assessment, plan, or know what is going to be needed at home.” (Director of Nursing)
“We need more timely planning…we can say on Monday that this patient is discharging next Monday…then Thursday comes and the rush kicks in. It doesn’t work.” (Director of Nursing)
“I don’t know what they are saying here. I will go see my own doctor when I get home. She will tell me what I need to take.” (Patient)
Theme two: care-team interactions and delivery of transitional care services
“I like to be available…I want [staff] to know they can come to me and ask for help…” (Nurse)“We have our rehabilitation meeting on Tuesday and everybody gets together and assesses what the patient needs when they are discharged…I would say that is our greatest strength here, having that open communication between all the disciplines.” (Quality Assurance Nurse)
“Some folks need to feel like they are driving the bus – for [patient name], we need to let her do that. The physical therapist…realized that the cervical collar was really the big issue – because she can’t see her feet when she wears it. We are very concerned to reduce her risk of falls, so we need to follow the therapist’s advice; we will work with her here until the collar is off.” (Social Worker)
“It’s just easier for me to do this [discharge planning] myself than to try to coordinate this work with someone else.” (Nurse Care Coordinator)
“I’m running around like a chicken with its head cut-off. The [Agency Name] did not order Oxygen – now on top of everything else, I have to figure that out.” (Nurse Care Coordinator)
“We write notes, but I do not think they are closely followed [by other staff]. So what I have to do is try to find the family…it is hard because they are not here when I am here…I can tell the rehabilitation director [what to tell them], but that is not a guarantee that it will make it to the family.” (Physical Therapist)
“If [staff members] have any issues and think [physician name] can help, they come to me, and say ‘can you, you know, talk to him about it.’” (Director of Nursing)
“Just having [team members] there gives us a chance to solve individual problems and to hear what the patient’s or family member’s questions are. This gives a chance to talk about the plan and prevent some of the last minute questions…” (Nurse)
“They helped set things up at home…even with the holidays, they found out what was needed, like learning my community worker’s name and working with him…I was worried. I would not have been able to handle it all.” (Patient)
“You have to teach [patient name] to compromise…We are asking her to make some big changes…You know, work with her so she can learn.” (Director of Nursing)
Theme 3: The challenge in providing evidence-based transitional care services
SNF | Week 1 | Week 2 | Week 3 | Week 4 |
---|---|---|---|---|
1 | • Thoroughly assessed needs for care at home • Reconciled medication lists • Taught medications and treatment goal | • Team meeting to engage patient and plan care at home • Contacted community physicians to plan medical goals | • Team taught self-management skills; • Social worker referred and activated community supports • MD taught goals and medications | • Provided written instructions • Scheduled MD follow-up • Did not transfer records to follow-up MD or contact patient at home |
2 | • Assessed functional needs • Did not assess patient/caregiver gaps in knowledge about dialysis or medications • Reconciled only hospital and SNF medication lists | • Rehabilitation therapists taught the patient (but not caregivers) • Did not engage family members in planning for the patient’s complex needs at home | • Assessed gaps in discharge and self-care ability for the patient at home • Team meeting to plan care at home • MD reconciled medications and taught the patient | • Referred support for new dialysis • Partial written instructions provided • Did not schedule MD follow-up, transfer records to follow-up MD or contact patient at home |
3 | • Assessed risk for falls and need for lower extremity rehabilitation. • Did not reconcile medication lists, identify caregiver needs, or address recent cardiac changes | • Planned care in SNF but did not plan the transition to home • Did not engage family members • The patient disengaged from SNF staff and planned goals with primary care | • The patient scheduled MD follow-up • Did not create integrated plan for care at home • Did not contact the community social worker • Taught self-management for mobility and transfer safety | • Referred home care • Taught a written list of discharge medications • Did not schedule MD follow-up, transfer records to primary care or contact the patient at home |
“I understand now. I can hold on [to] this thing even when I reach something up here.” (Patient)
“I feel like she [the patient] is coming into her own…She had the care plan meeting…then, physical therapy pulled her in [and taught her safety skills]…and she understands now what her goal is…I think she feels a whole lot better [about going home].” (Social Worker)
“This is a very, very, very overall equipped convalescent facility… everyone here pays attention to what you need, every detail.” (Patient)