More than 5 million individuals transition from hospitals to skilled nursing facilities (SNFs) annually, and the nurses in these SNFs typically play the primary role in receiving and initiating these individuals' care. Although hospital discharge processes and hospital discharge communications to primary care physicians have been well described,[2, 3] almost no prior work has been done on the nursing processes or on the SNF-based individual or system consequences of variation in transitional care quality. This is a critical oversight in the field of transitional care research, especially because discharge to a SNF is one of the strongest predictors of experiencing rehospitalization within 30 days.[4, 5] To design effective hospital–SNF transitional care interventions to reduce these rehospitalizations, the primary processes at the receiving end of these transitions must be better understood.
The objective of this study was to examine how 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. This was accomplished through a qualitative approach, which analyzed highly detailed information obtained in focus groups and interviews with practicing SNF nurses. This work suggests that high-quality, complete discharge communication is vital to safe and effective hospital–SNF transitions.
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This study represents the first in-depth examination of SNF nurses' work processes, perceived barriers, and outcomes associated with variation in the quality of hospital-to-SNF transitions. Nurses described numerous safety concerns, inefficiencies, and adverse individual and staff outcomes that commonly result from hospital-to-SNF transitions, with poor-quality discharge communication identified as the major barrier to safe and effective transitions. The information nurses received from hospitals was virtually always described as being inadequate because of missing or incomplete, conflicting, and inaccurate information. Poor-quality discharge communication produced a cyclical, inefficient process of gathering and reconciling information. These attempts often took the form of repeated calls back to discharging hospitals; were time-consuming; led to delays in care, individual and family dissatisfaction, greater rehospitalization risk, and greater staff stress and frustration; and perpetuated a negative SNF facility image. Occasionally, poor-quality discharge information led directly to inappropriate care, which compromised individual safety.
A lack of transitional care training among health professionals might contribute to poor-quality discharge communication and, to some extent, might explain the limited responsiveness SNF nurses receive in attempts to reconcile inadequate information. Accreditation guidelines for physician and nursing training programs are vague in terms of the type or extent of transitional care training that they must provide.[12-14] Considering the lack of focus in these guidelines, it is likely that nation-wide transitional care training is variable, and crucial topics, such as understanding the needs and resource limitations of nonhospital settings, may not be consistently addressed. A review of curricular interventions focused on transitional care found that only 32% included “introduction to care settings” as a learning objective, suggesting that more-detailed accreditation guidelines are needed to ensure that a minimum level of transitional care training and experience is included in all health professional training programs.
These findings also suggest that poor-quality discharge communication might be directly related to individual outcomes such as rehospitalization. Discharge summaries are the primary (and sometimes only) document accompanying individuals between care facilities and are the regular source of SNF admission orders.[2, 16-19] The frequent omission of recommended components in discharge summaries found in prior research is consistent with the findings of this qualitative study.[2, 20, 21]
Although it is clear from this study that an overwhelming amount of written discharge data interferes with effective communication, SNF nurses felt that a minimum standard set of components (Table 2) would be necessary to ensure high-quality individual safety and care for newly admitted SNF residents. Hospital providers may view the SNF nurses' requested component list as overly extensive or burdensome, but these discharge communications can dictate SNF care for up to 30 days for some individuals, especially those who do not see a prescribing provider until their 30-day Medicare SNF benefit recertification, so their quality and completeness is critical. Also, with the advent of new electronic medical record capabilities and the restructuring of health systems to focus on episodic care and population health (e.g., accountable care organizations), innovative technologies and programs may soon be available to ease this burden on the discharging hospital provider while generating higher-quality discharge communication that takes the needs of the end-user (e.g., SNF nurse) into account. The requested content list provided here can be used in the design of such innovative programs.
A number of existing interventions to improve care transitions could help to address this communication problem. Many of these transitional care interventions use nurse practitioners to bridge the gap between care settings soon after hospital discharge,[22, 23] but these programs are not available in many areas and often exclude individuals with dementia, an important SNF population. There is work being done at the national level to standardize information sharing across health systems, including the Continuity of Care Document, but the currently proposed document omits many of the informational components that SNF nurses deemed to be critical and leaves problems of communication timing and clarification unaddressed. The Institute for Healthcare Improvement and others have made important recommendations for improving care transitions, including direct nurse-to-nurse communication (“warm handoff”), but according to the SNF nurses in this study, the quality and content of these handoffs is often poor. The Interventions to Reduce Acute Care Transfers (INTERACT) program is a nursing home–based intervention that shows considerable promise for addressing this intersetting communication problem, especially if the program were more widely disseminated. The most recent version of INTERACT includes multiple tools to help improve collaboration between hospitals and nursing homes, and the information offered in this article may inform further evolution of the program. The SNF nurses in this study offered a number of interventions that they thought would be helpful, but more work is needed to design, refine, and disseminate nursing home–focused transitional care interventions. With the advent of payment penalties for hospitals with higher-than-average recidivism rates, there may be additional incentives for hospital systems to engage in partnerships with SNFs to improve the quality of transitional care.
This study has several limitations. The sample represents nurses working in geographically similar areas with a limited number of hospitals. Although these hospitals represent a variety of urban, rural, academic and community practice settings, they may not be representative of all hospitals nationwide. Furthermore, this study did not include for-profit nursing homes. Negative outcomes that the nurses described may be exaggerated in for-profit sites, which generally have lower staffing ratios. This study examined transitions to SNFs only, and findings may not be generalizable to individuals discharged to inpatient rehabilitation or other outpatient settings. No demographic information was collected on participating nurses, which limits the ability to interpret whether differences in work process might be related to educational training and background or past work experiences. Because no direct participant observation took place, it is impossible to affirm, with certainty, how often nurses encounter deficiencies in the quality of information and how they respond to those situations. Future studies in this area are needed.
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The findings of this study have been selected for poster presentation at the annual meetings of the American Geriatrics Society, the Gerontological Society of America, and the Midwest Nursing Research Society. The authors would like to acknowledge Peggy Munson for institutional review board assistance, Melissa Hovanes for project management and support, and Kristen Pecanac for assistance with data analysis. The authors have obtained written consent from all contributors who are not authors and are named in this section.
Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.
This project was supported by the National Institute on Aging Paul B. Beeson Patient-Oriented Research Career Development Award (K23AG034551, PI, Kind), in partnership with the American Federation for Aging Research, the John A. Hartford Foundation, the Atlantic Philanthropies, and the Starr Foundation and the Madison VA Geriatric Research, Education and Clinical Center (GRECC-Manuscript 2013–05). Roiland and Gilmore-Bykovskyi received support from the John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Program. Roiland's contributions were supported by an F31 National Research Service Award from the National Institute of Nursing Research (F31NR013097–01). Additional support was provided by the University of Wisconsin School of Medicine and Public Health's Health Innovation Program; the Community-Academic Partnerships core of the University of Wisconsin Institute for Clinical and Translational Research; and the Clinical and Translational Science Award program of the National Center for Research Resources, National Institutes of Health (1UL1RR025011). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Author Contributions: King: design; acquisition, analysis, and interpretation of data; drafting the article; final approval of the version to be published. Gilmore-Bykovskyi: design, analysis and interpretation of data, drafting and critical revision of the article, final approval of the version to be published. Roiland: acquisition, analysis, and interpretation of data; drafting of the article; final approval of the version to be published. Polnaszek: acquisition and interpretation of data, critical revision of the article, final approval of the version to be published. Bowers: design, analysis and interpretation of data, critical revision of the article, approval of final version to be published. Kind: conception; design, analysis, and interpretation of data; drafting and critical revision of the article; final approval of the version to be published.