System of Transition of Care

1 Annotated Bibliography on Transition of Care from Hospitals to Skilled Nursing Facilities Dana Broomes Walden University NURS 6201 Section 3 Leadership in Nursing and Healthcare March 20, 2020 2 Introduction There are many factors toward improving the quality of care for chronically ill older adults, enhancing transitions within acute hospital settings, and improving patient handoffs to and from acute care hospitals. The research indicates that there are existing gaps in care for these patients and their caregivers during critical transitions that can lead to adverse events, unmet needs, low satisfaction with care, and high rehospitalization rates (Naylor & Keating, 2008). Studies also show that there are key elements to improving these transitions of care and enhancing the support of family caregivers which are to remain focused on the patients’ and family caregivers’ needs, preferences, and goals, to utilize interdisciplinary teams guided by evidence-based protocols, to improve communication among patients, caregivers, and providers, and to use information systems to monitor care and outcomes (Naylor & Keating, 2008). The research suggests that comprehensive assessments of patients’ and caregivers’ needs should be performed at the time of the patients’ admissions to the hospital, since they often lack the knowledge, skills, and resources to properly manage their follow-on home health care (Naylor & Keating, 2008). The following annotated bibliography summarizes five scholarly articles that address different components in the transition of care that nurse leaders must focus on to safely manage patients’ continuity of care from acute care hospitals to skilled nursing facilities (SNFs). Annotated Bibliography Dizon, M., Zaltsmann, R., & Reinking, C. (2017). Partnerships in Transitions: Acute Care to Skilled Nursing Facility. Professional Case Management, 22(4), 163–173. Retrieved from https://doi-org.ezp.waldenulibrary.org/10.1097/ncm.0000000000000199 The purpose of this collaborative study was to describe the efforts and results of the work done to address the need to identify patients at high risk for unplanned readmission to hospitals 3 after being discharged to skilled nursing (SNFs). According to the study, in 2004, 34% of Medicare patients were readmitted to the hospital within 90 days of discharge, which resulted in an estimated cost of $17.4, and older adults discharged to SNFs have higher rates of unplanned readmissions due to their multiple comorbidities and complex inpatient care. Therefore, Dizon, Zaltsmann, & Reinking conducted a comprehensive review to identify the unmet needs of patients and caregivers that could ensure smooth transitions, educate patients and caregivers, and facilitate communication between acute care facilities and SNFs. The leadership teams of an acute care hospital in Northern California and eleven SNFs worked together to focus on collaboration, communication, and competency by identifying problem areas, objectives to address them, and actions necessary to achieve their established goals. They conducted monthly meetings to review unplanned readmissions that were evaluated by the hospital’s NP and SNF clinical staff to identify trends and action items.

These reviews helped to identify gaps in care and opportunities for improvement. Two case studies were also presented in the article that identified the major problem that the hospital was not consistent in providing correct information to the SNFs which resulted in the formulation of three objectives of the hospital-SNF partnership: the creation of standardized forms for transferring patients, including checklists for hospital to SNF and SNF to ED transfers, incorporating transitions work in the role of NPs to communicate directly with the bedside nurse with follow-up calls post transfers, and enhanced communication by video conferencing. The case studies also identified that end-of-life and palliative care was not adequately addressed by either agency which led to more thorough assessments of patients’ and caregivers’ needs and more collaborative communication with consistent messaging regarding end of life care options. 4 The multidisciplinary work between the hospital and contributing SNFs resulted in shared accountability, better communication based on teambuilding, enabled smooth transitions, and improved patient care. It involved bed-side staff and executive support with shared decision-making among facilities to improve workflow and communication between care settings. The study also identified future work that can be done, such as including provider to provider handoffs, collaboration with home health agencies, and the use of standardized protocols at SNFs to improve patient care while decreasing healthcare costs. Hirschman, K., Shaid, E., McCauley, K., Pauly, M., & Naylor, M. (2015). Continuity of Care: The Transitional Care Model. Online Journal Of Issues In Nursing, 20(3), 1. Retrieved from https://eds-b-ebscohost-com.ezp.waldenulibrary.org/eds/detail/detail? vid= 1&sid=7fe09b20-b81d-4202-8043-157089ce5a1e%40sessionmgr103&bdata=JnNpd GU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=26882510&db=mnh This article by Hirschman, Shaid, McCauley, and Naylor presents the Transitional Care Model (TCM), which is an evidence-based, a nurse-led intervention focused on older adults at risk for poor outcomes as they transfer between healthcare settings and attending providers. System of Transition of Care

The TCM focuses on the Triple Aim, improving care, enhancing outcomes for patients and family caregivers, and reducing healthcare costs for chronically ill, older adults. Randomized clinical trials have demonstrated the success of the TCM to improve acutely ill patients’ experiences, health, and quality of life outcomes with reduced rehospitalization rates and overall healthcare costs of the chronically ill. The authors summarize the model’s core components, which are screening, staffing, maintaining relationships, engaging patients and family caregivers, assessing and managing risks and symptoms, educating and promoting self-management, collaborating, promoting continuity, 5 and fostering coordination which are interconnected and part of a holistic care process. The staffing used in the TCM uses APRNs who are leading the care for their patients transitioning from acute hospital care and have been identified as high risk for poor outcomes. The APRNs maintain the responsibility for the daily delivery of transitional care services as well as overseeing other healthcare team members. They screen patients, conduct comprehensive assessments, establish trusted relationships with patients and caregivers, educating them and promoting self-management to keep them engaged in their healthcare plans. The APRNs also lead the way, promoting communication and connections between hospital, post-acute, and community-based staff to facilitate the transfer of essential information using secure email systems and electronic health records. The APRNs engaged with patients, caregivers, and other team members work to ensure that patients have smooth transitions of care with comprehensive treatment plans. The research team established metrics to benchmark adherence and measure the program’s outcomes. There is an ongoing study to help identify how health systems in America are adapting the TCM’s core components to improve continuity of care through transitions. The article states that, according to the Coalition for Evidence Based Policy, the TCM (2014) has been recognized as a “top-tiered, evidence-based approach” that could have a significant positive effect on Medicare beneficiaries transitioning from hospital to home. By adopting one or more of the TCM’s core components to local practices, nurse leaders can implement this care management approach to improve outcomes and assure that patients and their caregivers have the support and resources needed to help manage their care. Jusela, C., Struble, L., Gallagher, N. A., Redman, R., & Ziemba, A. (2017). Communication 6 Between Acute Care Hospitals and Skilled Nursing Facilities During Care Transitions. Journal of Gerontological Nursing, 43(3), 19–28. Retrieved from https://doi-org.ezp. waldenulibrary.org/10.3928/00989134-20161109-03 The findings of the research conducted by Jusela, Struble, Gallagher, Redman, and Ziemba also support the need for improved TCMs and better communication of information between acute care settings and SNFs for transitioning patients. The article cited an Institute for Healthcare Improvement’s study from 2014 that reported poor communication of medical information accounts for nearly 50% of errors during care transitions. These transitions have been identified as “vulnerable exchange points,” and care plans from one setting are often not communicated to the next care team. The study was a retrospective convenience sample chart audit, and all patients admitted to the SNF from an acute care hospital were examined. The checklist was based on local and national standards. It revealed the following discrepancies: transferring physician contact information was missing in 65%, medication lists were missing from 1%, steroid tapering instructions missing from 42%, antiarrhythmic instructions missing from 38%, duration/indication of anticoagulant medications missing from 25%, and antibiotic medications missing from 22% of the patient charts. The accuracy and completeness of the discharging providers’ instructions also affect patients’ transitions. There were multiple implications based on the results of this study. The data suggests the need for education and training of HCPs in both SNF and acute care settings, including developing standardized forms, designating leadership roles for accountability, and conducting quality improvement projects. The researchers also suggested cross-continuum team meetings and the creation of policies and procedures that allow for monitoring and collecting feedback 7 about discharge planning processes, including information transfer, clinical outcomes, patient satisfaction, patient understanding, and input from the provider and/or next care setting. Jusela, Struble, Gallagher, Redman, and Ziemba identified nurse leaders as positioned to identify recommended elements of data transfer for optimal patient outcomes and capable of making recommendations for policy reform and quality improvement projects, removing barriers to care. They suggest the creation of additional educational workshops that would create awareness of institutional capabilities and/or barriers and would also facilitate smoother transitions in care. Healthcare providers must be able to communicate effectively and provide patients and caregivers with the resources that will enable them to be engaged in their care plans. King, B. J., Gilmore-Bykovskyi, A. L., Roiland, R. A., Polnaszek, B. E., Bowers, B. J., & Kind, A. J. H. (2013). The consequences of poor communication during transitions from hospital to skilled nursing facility: a qualitative study. System of Transition of Care

Journal Of The American Geriatrics Society, 61(7), 1095–1102. Retrieved from: https://doi-org.ezp.waldenu library.org/10.1111/jgs.12328 According to King et al., there are multiple inadequacies of hospital discharge information, including regular problems with medication orders, little psychosocial or functional history, and inaccurate information regarding the current health status of patients when patients are transferring to SNFs. These inadequacies create delays in care, increased SNF staff stress, frustrated patients and family members, and increased risk of rehospitalization. With all the deficiencies identified in hospital‐to‐SNF transitions, poor discharge communication was listed as the primary barrier to safe and effective transitions. The article reports more than five million patients transition from hospitals to SNFs every year, and nurses are primarily responsible for receiving and initiating these individuals’ care. 8 The objective of this study was to examine the patients’ transitions of care, the barriers nurses experience, and the outcomes associated with variations in the quality of transitions by analyzing detailed information obtained in focus groups and interviews with practicing SNF nurses. The research suggests that high‐quality, complete discharge communication is crucial to safe and effective hospital–SNF transitions, and a lack of transitional care training among health professionals might contribute to poor‐quality discharge communication since accreditation guidelines for physician and nursing training programs are vague. Kerstenetzky, L., Birschbach, M. J., Beach, K. F., Hager, D. R., & Kennelty, K. A. (2018). Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: A targeted needs assessment using the Intervention Mapping framework. Research In Social & Administrative Pharmacy: RSAP, 14(2), 138–145. Retrieved from https://wwwsciencedirect-com.ezp.waldenulibrary.org/science/article/pii/S155174111630374 6?via%3Dihub A patients’ transition from a hospital to a SNF introduces the likelihood of medication errors. According to this study, three-fourths of hospital to SNF admissions had at least one medication discrepancy, and approximately 40% of medication errors are thought to be a result of inadequate medication reconciliation procedures during transitions, with 20% of these errors are believed to cause patient harm. This study reports on the development of a logic model used to explore methods for minimizing patient medication delays and errors while further improving handoff communication from hospital to SNF pharmacy staff to improve the quality of care for patients transitioning from hospital to SNF. 9 Communication handoff for patients discharging to SNFs is an interdisciplinary effort between providers, nurses, pharmacists, and social workers/case managers, but this process is not standardized across disciplines. The study identified a common theme among SNF staff of onedirectional discharge communication from the hospital with little opportunity for feedback on patient care concerns. It was also determined that certain communications are expected to occur as typical workflow, while some only occur if clarifications are necessary. It was determined that the handoff process for hospital discharge teams should be formalized, and the admitting SNF will receive handoff education about the contents of the hospital discharge packet to eliminate gaps in transitional care. Conclusion This annotated bibliography summarized five scholarly articles that address different components in the transition of care that nurse leaders must focus on to safely manage patients’ continuity of care from acute care hospitals to skilled nursing facilities (SNFs). The studies identified key elements in improving these transitions of care and enhancing the support of family caregivers. Since multidisciplinary teams are involved when transferring patient care, each member of the health care team must communicate clearly with each other, patients, and their family members to comprehensively manage care transitions to reduce healthcare costs, improve outcomes, and meet the needs of patients and their caregivers. Reference: Naylor, M., & Keating, S. A. (2008). Transitional Care. AJN American Journal of Nursing, 108(9), 58–63. Retrieved from https://doi-org.ezp.waldenulibrary.org/10.1097/ 01.NAJ.0000336420.34946.3a  System of Transition of Care