CARE IN NURSING

Transitional Care in Nursing Homes



Transitional Care in Nursing Homes

Introduction

Transitional care is recognized as an important strategy for supporting older adults as they make transitions between settings and providers of care. Two commonly described transitional care approaches are (a) to prepare older adults and their families with information, self-management strategies, and referrals to navigate care independently and (b) to support older adults and families with care coordination services for continuous coaching and education. At the core of transitional care, however provided, is the engagement and activation of older adults in plans for safe continuation and coordination of health care as they transition between settings of care.

Many studies have described the enduring positive effects of added transitional care coordinators on health outcomes for older adults after transitions from hospitals to home, most notably the reduction in rates of re-hospitalization and use of emergency services after discharge from hospitals to home. With evidence from hospital-based intervention studies, several models of transitional care have been developed, such as the Transitional Care Model, the Care Transitions Intervention, and the Reengineered Hospital Discharge Program. An important next step in transitional care research is to adapt these hospital-based models to new settings and patient populations with high risk for complications from transitions in care.

Post-acute care patients in nursing homes have emerged as large, new population of older adults at great risk for complications from transitions in care. Between 1999 and 2007, older adult use of nursing homes for post-acute care services increased by 32%, or from 1.4 to 1.8 million patients; thus, in 2007, more than 10% of all nursing home patients were admitted from hospitals for “short stay” post-acute care and expected discharges from nursing homes to home. Very little is known about the epidemiology, clinical needs, care processes, or care outcomes related to transitional care services for these post acute care patients in nursing homes.

It is known that they are a vulnerable patient population - they are often frail and dependent on informal caregivers for support. It is also known that the nursing home staff members, who traditionally provide care for long-term care patients, may lack expertise for providing transitional care to prepare the post-acute care patients for their transitions to home. Thus, post-acute care patients, who are vulnerable to complications from multiple transitions in care, may not receive the basic care required to prepare them for safe transitions from nursing homes to home (Wright 2009, 443).

Transitional care, provided by existing nursing home staff for post-acute care patients in nursing homes, has not been studied and thus critical data are missing which explicitly describe (a) nursing home structures which facilitate transitional care (e.g., protocols and human resources), (b) care processes designed to promote safe care transitions (e.g., patient teaching and care coordination across the continuum of care), (c) team processes or interaction strategies for coordinating transitional care (e.g., staff interaction patterns which adapt care processes to individual patient needs), and (d) outcome measurements of the quality of transitional care ...