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Table 1 Conceptual model: transitional care in SNFs

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

Organizational Structure: Three organizational supports in SNFs that facilitate delivery of transitional care services [18].

Structure

Definition

Staff knowledge

Professional staff members (e.g., physicians, nurses, rehabilitation therapists and social workers) are (a) available to patients and family caregivers and (b) skilled in delivering transitional care.

Care routines

Predictable schedules that staff members use to deliver transitional care, including team meetings focused on patient and caregiver needs, family and patients meetings, and cycles of care delivery and assessment to monitor outcomes.

Tools

Templates and information technology that staff use to document transitional care services and for create individualized patient and caregiver written instructions.

Care-team Interactions: Informal interactions among patients, caregivers and staff that help them form relationships (connect), exchange information, and solve problems [20, 33].

Interaction

Definition

Connect

Staff members are (a) approachable for building relationships with patients and family caregivers; (b) pitch-in to help each other, patients and family caregivers; (c) recognize each other as care team members.

Exchange information

Staff members (a) listen to each other, patients, and family caregivers; (b) relay and verify the accuracy of new information; (c) communicate in pairs and larger groups of care-team members.

Solve problems

Staff members ask questions and give feedback to develop new information or understanding. Groups of care-team members participate in conversations to solve emerging problems in care.

Transitional Care Services: Eight evidence-based care processes that promote continuity and coordination of care as older adults transition between settings and providers of care [1113].

Process

Definition

Assess

Evaluates patient and caregiver preferences, strengths and needs related to health care for ensuring patients’ self-care ability and safety at home.

Plan

Creates multidisciplinary goals and measures to deliver transitional care based on assessments of patient and caregiver preferences, strengths and needs.

Engage

Collaborates with patients and caregivers to ensure that (a) implemented plans are congruent with their preferences and goals and (b) patients feel motivated to implement transition plans.

Reconcile medication

Verifies a correct medication list, using medications lists from home, hospital and SNF stays, and orders for planned care at home. Inaccuracies and errors of omission or commission are corrected.

Refer

Schedules and confirms the feasibility of services planned for care at home, e.g., MD appointments, home care, social services, rehabilitation, and tests/procedures.

Educate

Ensures that patients and caregivers have a written record and clear understanding of (a) the transition plan; (b) the name, purpose, dosage, administration, and side effects of medications, and (c) how to recognize and respond to warning signs changes in health or medical conditions.

Transfer

Sends timely and accurate summaries of SNF care and plans for the transition home to community providers of care.

Follow-up

Provides follow-up phone calls or home visits to promote patients’ and family caregivers’ implementation of transition plans at home.