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 [11–13]. | |
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. |