transitional care for post-acute care patients in nursing homes mark toles, msn, rn
TRANSCRIPT
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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
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.
Prepare older adults who receive post-acute care in nursing homes for safe transitions from nursing homes to home.
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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-
hospitalized53% 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 Processese.g.,inpatient & home visits engage caregiverscreate transition planteach medicationstransfer information
Added Staff e.g., APRNs
Outcomese.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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StructureCare
ProcessesOutcomes
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
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Structure
Stable facility-level features that support care processes
Examples1. Care-team members2. Procedure for sending records to community provider3. 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
Examples1. Develop a transition plan with patients & caregivers2. Teach patients about medications & treatments3. Draft a written care plan4. 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.