Skilled Nursing Facilities Staff Research Articles

Hospital-Skilled Nursing Facility Collaboration: A Mixed-Methods Approach to Understanding the Effect of Linkage Strategies.

To characterize the nature and degree of hospitals' efforts to collaborate with skilled nursing facilities (SNFs) and associated patient outcomes. Qualitative data were collected through 138 interviews with staff in 16 hospitals and 25 SNFs in eight markets across the United States in 2015. Quantitative data include Medicare claims data for the 290,603 patients discharged from those 16 hospitals between 2008 and 2015. Semi-structured interviews with hospital and SNF staff were coded and used to classify hospitals' collaboration efforts with SNFs into high versus low collaboration hospitals, and risk-adjusted, claims-based hospital readmission rates from SNF were compared. Hospital collaboration efforts were defined as establishing SNF partners, transition management initiatives, and hospital staff visits to SNFs. High collaboration hospitals were more likely to send patients to SNFs (as opposed to home, home with home health, or other PAC settings), sent a higher share of patients to high quality SNFs, and had fewer hospital readmissions from SNF sooner than did low collaboration hospitals. Although collaboration with SNF requires significant administrative and clinical time investment, it is associated with positive patient outcomes.

Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities.

Prior studies have not described strategies for implementing transitional care in skilled nursing facilities (SNFs). As part of the Connect-Home study, we pilot tested the Transition Plan of Care (TPOC) template, an implementation tool that SNF staff used to deliver transitional care. A retrospective chart review was used to describe the impact of the TPOC template on three implementation outcomes: reach to patients, staff adoption of the template, and staff fidelity to the intervention protocol for transition care planning. The template reached 100% of eligible patients (N = 68). Adoption was high, with documentation by four disciplines in 90.6% of patient records (N = 61). Fidelity to the intervention protocol was moderately high, with 73% of documentation that was concordant with the protocol. Our findings suggest an electronic medical record (EMR)-based implementation tool may increase the ability of staff to prepare older adults and their caregivers for self-care at home. Further research is needed to test the efficacy of the protocol on patient outcomes after transitions from SNF to home.

Partnerships in Transitions: Acute Care to Skilled Nursing Facility.

Older adults, in particular those discharged to skilled nursing facilities (SNFs), are at high risk for readmission. As part of a multifaceted approach to reduce readmissions, a community hospital initiated a 3-prong approach (Collaboration, Communication, and Competency) and partnered with regional SNFs. El Camino Hospital, an independent, locally owned, not-for-profit district, acute care hospital in Northern California, and 11 participating SNFs in the same region. Collaboration: The combined leadership team developed a case report form and instituted regular reviews of 7-day readmissions. Communication: Standardized form for transferring patients to SNFs, form for transfer from SNF to emergency department, and consent form to enable SNFs to administer antipsychotic medications were developed. Regular phone and video conferencing between clinicians at the hospital and receiving SNF were instituted. Competency: Educational series to recognize and intervene to prevent readmission, and mutual exchange of best practices among hospital and SNF staff, were instituted. Continued work among ECH and the participating SNFs has improved the flow of information in both directions; favorable results from the broader study to reduce readmissions hospital-wide provide support for these efforts. Initiating collaboration with the SNFs is imperative in the changing health care landscape. Because of the complexity of the problem, acute care facilities and SNFs need to create a partnership to ensure smooth patient transition. Communication between care settings is essential in achieving optimum patient outcomes.

Implementation of a Person-Centered Medical Care Model in a Skilled Nursing Facility: A Pilot Evaluation

ObjectivesThe objective of this study was to evaluate the feasibility and impact of implementing a person-centered medical care model for post-acute care residents within a skilled nursing facility (SNF). DesignA mixed-method (qualitative and quantitative) pilot evaluation. SettingAn 89-bed SNF located within a large midwestern city. ParticipantsForty SNF post-acute patients admitted to the facility during a 6-month period were enrolled in the pilot evaluation. The patients were 75% women, 57% African American, and had an average age of 73. To meet inclusion criteria, patients must have been admitted to the facility for rehabilitation with a plan for community discharge, and be cognitively able to consent as indicated by a cognitive screening tool or assent to participation with family member consent. InterventionThe person-centered medical care model included (1) biweekly interdisciplinary care plan meetings, scheduled at a time of patients' preference and held in the patient's room; (2) patient selection of health-related goals that guide team discussions; (3) use of lay-language that facilitated patient understanding; (4) team accountability to the patient for patient care preferences; and (5) monthly care-team meetings to exchange feedback regarding the team's performance and the model. MeasurementEvaluation data included admission and discharge Patient Activation Measure surveys; admission and discharge Care of Chronic Conditions surveys; admission and biweekly modified Castle Satisfaction Surveys; admission and discharge Patient and Caregiver Engagement surveys; and semistructured interviews with a sample of staff, family members, and patients. ResultsA significant (P < .01) improvement was noted between admission and discharge on both the Care for Chronic Conditions and the Patient Activation Measure surveys. Patient satisfaction surveys trended toward higher ratings over time on most questions, with significant improvement in 2 questions addressing satisfaction with their medical provider. Interviews revealed a perception that the model encouraged an environment of respect and honesty in patient communications, and an overall positive experience. The challenges of scheduling and time were noted by respondents. ConclusionsImplementation of person-centered medical care within an SNF was feasible, yet required changing care processes to better address individual goals and facilitate communication among patients, providers, and SNF staff. Overall pilot results indicated that patients and staff members viewed the person-centered care experience positively. Further research is needed to examine long-term effects of the model on resident outcomes.

Potentially Avoidable Readmissions of Patients Discharged to Post-Acute Care: Perspectives of Hospital and Skilled Nursing Facility Staff.

Hospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF perspectives. To determine the percentage of readmissions from post-acute care that are considered potentially avoidable from hospital and SNF perspectives. Prospective cohort study. One academic medical center and 23 SNFs. We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days. Hospital-based physicians and SNF-based staff performed structured root-cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions. The 30-day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively. A substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.

A Cluster of Group A Streptococcal Infections in a Skilled Nursing Facility-the Potential Role of Healthcare Worker Presenteeism.

To determine the extent of a group A streptococcus (GAS) cluster (2 residents with invasive GAS (invasive case-patients), 2 carriers) caused by a single strain (T antigen type 2 and M protein gene subtype 2.0 (T2, emm 2.0)), evaluate factors contributing to transmission, and provide recommendations for disease control. Cross-sectional analysis and retrospective review. Skilled nursing facility (SNF). SNF residents and staff. The initial cluster was identified through laboratory notification and screening of SNF residents with wounds. Laboratory and SNF administrative records were subsequently reviewed to identify additional residents with GAS, oropharyngeal and wound (if present) swabs were collected from SNF staff and residents to examine GAS colonization, staff were surveyed to assess infection control practices and risk factors for GAS colonization, epidemiologic links between case-patients and persons colonized with GAS were determined, and facility infection control practices were assessed. No additional invasive case-patients were identified. Oropharyngeal swabs obtained from all 167 SNF residents were negative; one wound swab grew GAS that was the same as the outbreak strain (T2, emm 2.0). The outbreak strain was not identified in any of the 162 staff members. One of six staff members diagnosed with GAS pharyngitis worked while ill and had direct contact with invasive case-patients within a few weeks before their onset of symptoms. Additional minor breaches in infection control were noted. Sick healthcare workers may have introduced GAS into the SNF, with propagation by infection control lapses. "Presenteeism," or working while ill, may introduce and transmit GAS to vulnerable in SNF populations. Identification of an invasive GAS case-patient should trigger a prompt response by facilities to prevent further transmission and workplace culture, and policies should be in place to discourage presenteeism in healthcare settings.

Hospital Transfers of Skilled Nursing Facility (SNF) Patients Within 48 Hours and 30 Days After SNF Admission

BackgroundClose to 1 in 5 patients admitted to a skilled nursing facility (SNF) are readmitted to the acute hospital within 30 days, and a substantial percentage are readmitted within 2 days of the SNF admission. These rapid returns to the hospital may provide insights for improving care transitions between the acute hospital and the SNF. ObjectivesTo describe the characteristics of SNF to hospital transfers that occur within 48 hours and 30 days of SNF admission based on root cause analyses (RCAs) performed by SNF staff, and identify potential areas of focus for improving transitions between hospitals and SNFs. DesignTrained staff from SNFs enrolled in a randomized, controlled clinical trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program performed retrospective RCAs on hospital transfers during a 12-month implementation period. SettingSNFs from across the United States. Participants64 of 88 SNFs randomized to the intervention group submitted RCAs. InterventionsSNFs were implementing the INTERACT quality improvement program. MeasuresData were abstracted from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers. ResultsAmong 4658 transfers for which data on the time between SNF admission and hospital transfer were available, 353 (8%) occurred within 48 hours of SNF admission, 524 (11%) 3 to 6 days after SNF admission, 1450 (31%) 7 to 29 days after SNF admission, and 2331 (50%) occurred 30 days or longer after admission. Comparisons between transfers that occurred within 48 hours and within 30 days of SNF admission to transfers that occurred 30 days or longer after SNF admission revealed several statistically significant differences between patient risk factors for transfer, symptoms and signs precipitating the transfers, and other characteristics of the transfers. Hospitalization in the last 30 days and year was significantly more common among those with rapid returns to the hospital. Shortness of breath was significantly more common among those transferred within 48 hours or 30 days, and falls, functional decline, suspected respiratory infection, and new urinary incontinence less common. SNF staff rated a higher proportion of transfers within 30 days versus 30 days or longer as potentially preventable (25.1% vs 21.5%, P = .005). Case descriptions derived from the QI tools of transfers back to the hospital within 48 hours of SNF admission illustrate several factors underlying these rapid returns to the hospital. ConclusionRCAs on transfers back to the hospital shortly after SNF admission provide insights into strategies that both hospitals and SNFs can consider in collaborative efforts to reduce potentially avoidable hospital readmissions.

Transitional care in skilled nursing facilities: a multiple case study.

BackgroundAmong hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement.MethodsIn this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services.ResultsStaff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions.ConclusionsOrganizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care.

Lessons Learned From Root Cause Analyses of Transfers of Skilled Nursing Facility (SNF) Patients to Acute Hospitals: Transfers Rated as Preventable Versus Nonpreventable by SNF Staff

BackgroundDetermining if a transfer of a skilled nursing facility (SNF) patient/resident to an acute hospital is potentially avoidable or preventable is challenging. Most previous research on potentially avoidable or preventable hospitalizations is based on diagnoses without in-depth root cause analysis (RCA), and few studies have examined SNF staff perspective on preventability of transfers. ObjectivesTo examine factors associated with hospital transfers rated as potentially preventable versus nonpreventable by SNF staff. DesignTrained staff from SNFs enrolled in a randomized controlled clinical trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program performed retrospective RCAs on hospital transfers during a 12-month implementation period. SettingSNFs from across the United States. ParticipantsSixty-four of 88 SNFs randomized to the intervention group submitted RCAs with a rating of whether the transfer was determined to be potentially preventable or nonpreventable. InterventionsSNFs were implementing the INTERACT Quality Improvement (QI) program. MeasuresData were abstracted from the INTERACT QI tool, a structured, retrospective RCA on hospital transfers. ResultsA total of 4527 RCAs with a rating of preventability were submitted during the 12-month implementation period, of which 1044 (23%) were rated as potentially preventable by SNF staff. In unadjusted univariate analyses, factors associated with ratings of potentially preventable included acute changes in condition of fever, decreased food or fluid intake, functional decline, shortness of breath, and new urinary incontinence; other factors included the clinician, resident, and/or family insisting on the transfer, transfers that occurred fewer than 30 days from SNF admission and that occurred on weekends, transfers ordered by a covering physician (as opposed to the primary physician), and transfers that resulted in an emergency department (ED) visit with return to the SNF. Factors associated with ratings of nonpreventable included on-site evaluation by a physician or other clinician, and transfers related to falls. Among factors precipitating the transfers, clinician and resident and/or family insistence on transfer, and transfers related to fever and falls remained significant in a multivariate analysis. There were no significant differences among characteristics of SNFs that rated a relatively high versus low proportion of transfers as potentially preventable. ConclusionSNF staff rated a substantial proportion of transfers as potentially preventable on retrospective RCAs. Factors associated with ratings of preventability, as well as illustrative case examples, provide important insights that can assist SNFs in focusing education and care process improvements in order to reduce unnecessary hospital transfers and their associated morbidity and costs.

Feeding Intolerance and Edema in Children and Adults with Severe Neurological Impairment: Features in the Last Year of Life (TH306)

terminal delirium. There are clear and widely accepted guidelines in the hospice literature for the treatment of agitation. On the other hand, skilled nursing facilities (SNFs) are reporting increasing regulatory pressure to limit the use of psychoactive medications, specifically antipsychotics and benzodiazepines. These restrictions have increased in recent years due to the concern over their overuse as ‘‘chemical restraints’’ for nursing home residents with behavioral problems. In addition, concern over increased mortality with antipsychotic medication use and other side effects have led to crackdowns on use by the regulatory bodies that oversee nursing homes. This can lead to conflicts between the nursing homes and hospice agencies. Frequently, nursing home staff demand to have psychoactive medications removed from the hospice patient’s medication profile. They will ask the hospice staff to pursue invasive tests to work up delirium or ask the hospice to use alternative medications with a less beneficial safety profile. This talk will address the conflicting priorities between hospice and SNF staff in regard to the pharmacologic treatment of delirium/agitation. By way of case presentations and didactics, this session will provide the attendee with current data on pharmacologic treatment of delirium/agitation, with discussion of black box warnings on some antipsychotic medications, an update on Medicare/other governing bodies’ regulations of antipsychotic medication use with an emphasis on SNF strategies to successfully collaborate with SNF to manage agitated SNF patients on hospice.

Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals: Lessons Learned for Reducing Unnecessary Hospitalizations

BackgroundPerforming root cause analyses (RCA) on transfers of skilled nursing facility (SNF) patients to acute hospitals can help identify opportunities for care process improvements and education that may help prevent unnecessary emergency department (ED) visits, hospitalizations, and hospital readmissions. ObjectivesTo describe the results of structured, retrospective RCAs performed by SNF staff on hospital transfers to identify lessons learned for reducing these transfers. DesignSNFs enrolled in a randomized, controlled implementation trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program submitted RCAs on hospital transfers during a 12-month implementation period. SettingSNFs from across the United States that volunteered and met the enrollment criteria for the implementation trial. ParticipantsSixty-four of 88 SNFs randomized to the intervention group performed and submitted retrospective RCAs on hospital transfers. InterventionsSNFs received education and technical assistance in INTERACT implementation. MeasuresData were summarized from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers. ResultsA total of 4856 QI tools were submitted during the 12-month implementation period. Most transfers were precipitated by multiple symptoms and signs, many of them nonspecific. Patient and/or family preference or insistence was noted to have played a role in 16% of the transfers. Hospital transfers were relatively equally distributed among days of the week, and 29% occurred on the night or evening shift. Approximately 1 in 5 transfers occurred within 6 days of SNF admission from a hospital, and 1 in 10 occurred within 2 days of SNF admission. After completing the RCA, SNF staff identified 1044 (23%) of the transfers as potentially preventable. Common reasons for these ratings included recognition that the condition could have been detected earlier and/or could have been managed safely in the SNF, and that earlier advance care planning and discussions with patients and families about preferences for care may have prevented some transfers. ConclusionSummarizing findings from RCAs of transfers of SNF patients to acute hospitals can provide important insights into areas of focus for care process improvements and related education that may help prevent unnecessary ED visits, hospital admissions, and readmissions.

Process Evaluation of a Quality Improvement Project to Decrease Hospital Readmissions From Skilled Nursing Facilities

ObjectiveTo describe and evaluate the impact of quality improvement (QI) support provided to skilled nursing facilities (SNFs) by a Quality Improvement Organization (QIO). DesignRetrospective, mixed-method, process evaluation of a QI project intended to decrease preventable hospital readmissions from SNFs. SettingFive SNFs in Connecticut. ParticipantsSNF Administrators, Directors of Nursing, Assistant Directors of Nursing, Admissions Coordinators, Registered Nurses, Certified Nursing Assistants, Receptionists, QIO Quality Improvement Consultant. InterventionQIO staff provided training and technical assistance to SNF administrative and clinical staff to establish or enhance QI infrastructure and implement an established set of QI tools [Interventions to Reduce Acute Care Transfers (INTERACT) tools]. MeasurementsBaseline SNF demographic, staffing, and hospital readmission data; baseline and follow-up SNF QI structure (QI Committee), processes (general and use of INTERACT tools), and outcome (30-day all-cause hospital readmission rates); details of QIO-provided training and technical assistance; QIO-perceived barriers to quality improvement; SNF leadership-perceived barriers, accomplishments, and suggestions for improvement of QIO support. ResultsSuccess occurred in establishing QI Committees and targeting preventable hospital readmissions, as well as implementing INTERACT tools in all SNFs; however, hospital readmission rates decreased in only 2 facilities. QIO staff and SNF leaders noted the ongoing challenge of engaging already busy SNF staff and leadership in QI activities. SNF leaders reported that they appreciated the training and technical assistance that their institutions received, although most noted that additional support was needed to bring about improvement in readmission rates. ConclusionThis process evaluation documented mixed clinical results but successfully identified opportunities to improve recruitment of and provision of technical support to participating SNFs. Recommendations are offered for others who wish to conduct similar projects.

Universal Postoperative Hip Instruction Protocol for Rehabilitation in Rural Skilled Nursing Facilities.

Hip fractures among the elderly increase the incidence of mortality and other health-related complications, lead to poor quality of life, and create major economic challenges. Elderly individuals often reside in rural skilled nursing facilities (SNFs) for rehabilitation after undergoing surgical fixation for a hip fracture. Orthopedic providers (OPs) can develop protocols that will encourage continuity of postoperative orthopedic follow-up care, guiding and educating SNF staff in best practices, and encouraging regular communication between SNF staff and OPs. The purpose of this article is to describe how an orthopedic practice developed a universal postoperative hip instruction protocol (UP-HIP) to promote a streamlined approach to postoperative follow-up assessment and rehabilitation for the elderly residing in rural SNFs. The overall goal of the UP-HIP is to provide the OP with assessment findings remotely and avoid putting frail elderly patients at risk by physically transporting them to and from follow-up appointments with the OP. Orthopedic clinic setting and rural SNFs. Comprehensive postoperative protocols focused on elderly patients with hip fracture in rural SNFs serve to improve remote communication during the rehabilitation phase and guide SNF in a coordinated approach to postoperative follow-up care. Future recommendations include the addition of telehealth technology to allow for remote real-time visual assessments by the OP while the elderly patient with hip fracture remains in the SNF environment. The UP-HIP allows the OP and case manager to ensure continuity of postoperative care by conducting remote follow-up postoperative visits with elderly patients with hip fracture while they remain in the rural SNF setting. Comprehensive evidence-based protocols assist OPs and case managers with remotely monitoring rehabilitation progress in the rural SNF setting more efficiently and consistently. Telehealth technology added to evidence-based protocols enables the OP and case manager to conduct real-time visual assessments of the patient without the patient having to leave the rural SNF setting.

Changes to hospice attending physician rules

Performing root cause analyses (RCA) on transfers of skilled nursing facility (SNF) patients to acute hospitals can help identify opportunities for care process improvements and education that may help prevent unnecessary emergency department (ED) visits, hospitalizations, and hospital readmissions.To describe the results of structured, retrospective RCAs performed by SNF staff on hospital transfers to identify lessons learned for reducing these transfers.SNFs enrolled in a randomized, controlled implementation trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program submitted RCAs on hospital transfers during a 12-month implementation period.SNFs from across the United States that volunteered and met the enrollment criteria for the implementation trial.Sixty-four of 88 SNFs randomized to the intervention group performed and submitted retrospective RCAs on hospital transfers.SNFs received education and technical assistance in INTERACT implementation.Data were summarized from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers.A total of 4856 QI tools were submitted during the 12-month implementation period. Most transfers were precipitated by multiple symptoms and signs, many of them nonspecific. Patient and/or family preference or insistence was noted to have played a role in 16% of the transfers. Hospital transfers were relatively equally distributed among days of the week, and 29% occurred on the night or evening shift. Approximately 1 in 5 transfers occurred within 6 days of SNF admission from a hospital, and 1 in 10 occurred within 2 days of SNF admission. After completing the RCA, SNF staff identified 1044 (23%) of the transfers as potentially preventable. Common reasons for these ratings included recognition that the condition could have been detected earlier and/or could have been managed safely in the SNF, and that earlier advance care planning and discussions with patients and families about preferences for care may have prevented some transfers.Summarizing findings from RCAs of transfers of SNF patients to acute hospitals can provide important insights into areas of focus for care process improvements and related education that may help prevent unnecessary ED visits, hospital admissions, and readmissions.

Special Considerations for Older Adults With Diabetes Residing in Skilled Nursing Facilities.

About 25% of all residents of skilled nursing facilities (SNFs) have diabetes, and that proportion is expected to increase. SNF residents with diabetes have special needs related to nutrition, hydration, physical activity, and medical therapy. Vigilant assessment and maintenance of safety is also crucial for such patients, including but not limited to issues such as hyper- and hypoglycemia, polypharmacy, falls, lower-extremity problems, and transitions of care. Interventions to provide stable glycemic control; ensure adequate nutrition, hydration, and physical activity; decrease polypharmacy; prevent falls; facilitate transitions of care; and improve the diabetes-related knowledge of SNF staff can help to meet these needs. Although this article focuses on SNFs, many of the topics covered also apply to elderly people with diabetes in other long-term care settings.

Hospitals Seek to Better Understand Nursing Facilities

Hospitals Seek to Better Understand Nursing Facilities

The consequences of poor communication during transitions from hospital to skilled nursing facility: a qualitative study.

To examine how skilled nursing facility (SNF) nurses transition the care of individuals admitted from hospitals, the barriers they experience, and the outcomes associated with variation in the quality of transitions. Qualitative study using grounded dimensional analysis, focus groups, and in-depth interviews. Five Wisconsin SNFs. Twenty-seven registered nurses. Semistructured questions guided the focus group and individual interviews. SNF nurses rely heavily on written hospital discharge communication to transition individuals into the SNF effectively. Nurses cited multiple inadequacies of hospital discharge information, including regular problems with medication orders (including the lack of opioid prescriptions for pain), little psychosocial or functional history, and inaccurate information regarding current health status. These communication inadequacies necessitated repeated telephone clarifications, created care delays (including delays in pain control), increased SNF staff stress, frustrated individuals and family members, contributed directly to negative SNF facility image, and increased risk of rehospitalization. SNF nurses identified a specific list of information and components that they need to facilitate a safe, high-quality transition. Nurses note multiple deficiencies in hospital-to-SNF transitions, with poor quality discharge communication being identified as the major barrier to safe and effective transitions. This information should be used to refine and support the dissemination of evidence-based interventions that support transitions of care, including the Interventions to Reduce Acute Care Transfers program.

Staff Interaction Strategies That Optimize Delivery of Transitional Care in a Skilled Nursing Facility

After hospitalization, more than 1.5 million older adults each year receive postacute care in skilled nursing facilities (SNFs). Transitional care services, designed to prepare older SNF patients (and their family caregivers) for their transitions from an SNF to home, have rarely been studied. Thus, we conducted a longitudinal, multiple case study of transitional care provided in an SNF to explore the care processes and staff interaction strategies that SNF staff members used to optimize delivery of transitional care. Using qualitative data from 89 interviews, 118 field observations, and 70 chart, or document reviews, we observed that transitional care services were not solely formalized processes, but rather were embedded in the interactions among older adult patients, their family caregivers, and members of interdisciplinary care teams. We found, moreover, that staff member interactions with patients and family caregivers increased the capacity of patient care teams for optimizing patient-centered care, information exchange, and coordination of transitional care.

Abstract 225B: Nursing Home Care Quality and 30-Day Readmission Rates for patients with Heart Failure

Background: Acute decompensated heart failure (ADHF) is one of the most frequent cause for hospitalization in the United States but little is known about how the quality of care provided by the skilled nursing facilities (SNFs) influences readmission rates. Objectives: 1)To determine the association between care quality reported on Medicare's Nursing Home Compare website and 30-day risk-adjusted readmission rate (RAR) for ADHF. 2) To assess the correlation of processes of care and characteristics of SNFs with 30-day RAR. Methods: Retrospective cohort study at Baystate Medical Center, a 659-bed tertiary care hospital. Subjects: Patients aged ≥18 years discharged to 17 local SNFs after hospitalization for ADHF from November 2008 to October 2011. SNF quality of care was assessed based on the quality rating (health inspection, quality measures and staff rating) obtained from www.medicare.gov/NHCompare (range 1 to 5 stars). Based on the distribution of quality ratings, SNFs with only 1 star were considered lower quality. A telephone survey about SNF characteristics (e.g. physician hours, number of beds, licensed nurse's minutes) and processes of care (e.g. telemonitoring capability, onsite IV lasix, Heart failure (HF) treatment protocol) was completed by each director of nursing. RAR's were calculated using a mixed-effects logistic regression model adjusting for demographics, comorbidities and clinical characteristics of the patients. Results: Of the 605 discharges (491 patients), 121 were readmitted within 30-days, 57 were ADHF related; 64% were female, 86% white and median age was 84 years (interquartile range 13). Nearly all (99%) patients had Medicare or Medicaid. At discharge, 37% had ejection fraction &lt;40% and 60% had at least one high-risk comorbidity (e.g. coronary artery disease, hypertension, atrial fibrillation). Higher quality SNFs (58%) were more likely to be non-profit and had more beds. The 30-day all-cause RAR was 19% (95% CI 14 -23) and 22% (95% CI 17 - 26) and the 30-day ADHF RAR was 9% (95% CI 6 -11.6) and 10% (95% CI 7 - 12.9) for higher and lower quality SNF's respectively. Both all-cause and ADHF RARs declined significantly between 2008- 2011 (P=0.02, χ2 test of trend). Although RAR were slightly lower in higher quality SNFs, these differences were not statistically significant in either adjusted or unadjusted models. Higher SNF staff ratings was marginally correlated with lower readmission rates (Spearmean R = - 0.39, p = 0.05). Self-reported processes of care (e.g. telemonitoring capability, weight graph), as well as SNF care structure (e.g. physician hours) did not correlate with RAR. Conclusions: Overall Quality rating reported on www.medicare.gov/NHCompare, as well as processes of care performed by SNFs were not associated with RARs for patients with Heart failure. Higher staff ratings correlated with lower RAR.

Reducing Heart Failure Hospital Readmissions From Skilled Nursing Facilities

Readmission rates for heart failure patients are a Center for Medicare & Medicaid and Joint Commission core measure. At this urban Midwestern medical center, the 6-month baseline skilled nursing facility (SNF) readmission rate was 30%. Nurse case management implemented a process to decrease the rate for this population. Follow-up phone calls were in place for patients discharged to home, but a gap remained in those discharged to SNFs. Nurse case management developed a follow-up phone call process within 48 hours of discharge to the registered nurse/licensed practical nurse in the SNFs to verify that: 1. Daily morning weights were ordered. 2. Parameters to contact primary care provider if weight gain was greater than 3 pounds per day or 5 pounds per week. 3. 2 gram sodium restricted diet was ordered. 4. Appropriate diuretic was ordered and reconciled. 5. Follow-up provider visits were made, for patient to be seen within 3 to 5 days following discharge. Acute inpatient care settings. The phone calls resulted in improved continuity of care and clarification of discharge orders. The opportunity for question-and-answer time between the hospital and the SNF nurse provided just-intime education; relationships have also been strengthened. Recent data show that the current readmission rate averages 11.32% (a decrease from 30%). This nurse case management–driven process of follow-up phone calls between the hospital and SNF staff to reduce readmission rates in heart failure patients resulted in improved continuity of care and clarification of discharge orders. This simple, innovative process allowed for improved continuity of care and partnerships between inpatient hospitalization and the SNF, thereby reduced transcription errors and improved patient health outcomes. Enhanced communication between providers allowed for a significant reduction in readmissions from SNFs to the hospital.