Transitioning from a skilled nursing facility to home care can be frightening and challenging for patients and their families and caregivers. Especially if the patient is frail and elderly with multiple chronic conditions, this transition can be particularly rocky if healthcare professionals and the patient’s caregivers don’t adequately prepare for the transition and establish effective communication about care and the patient’s ongoing and future needs. 

Improving the Transition from Skilled Nursing Care to Home

To address this gap and offer tools and resources to improve care, the United Hospital Fund released a new toolkit to ensure the transition from skilled nursing facilities to home care is as smooth and painless as possible. The 26-page toolkit, Heading Home from a Skilled Nursing Facility: Interventions and Tools for Improving the Transition, can be downloaded from the UHF’s website.

Identifying the Challenges 

The initiative comes after two years of UHF’s collaborative work with eight skilled nursing facilities in the New York metropolitan area, including surveying 263 patients and 249 caregivers at those facilities regarding the most vulnerable, frustrating, or challenging aspects of them.  

The good news from the survey findings was that at least 8 in 10 patients reported receiving and understanding their discharge instructions. In addition, more than 7 in 10 reported receiving the services they needed after discharge, including medications, equipment, and other assistance. 

Further, at least 75% of the respondents said they received home health care services on time. 

While those big picture items seemed well managed during the transition, it was the “little things“—that can become big things—and the psychosocial aspects where patients and caregivers felt they had less support and attention than they needed. For example, despite so many patients saying they received and understood their discharge instructions, more than two out of three patients and caregivers had trouble understanding the patients’ medications and side effects—an issue that could lead to poor compliance or inaccurate dosing. Similarly, more than half the respondents needed better information about identifying the signs and symptoms related to their condition, including worsening conditions, once the patients were home. 

The other gaps dealt with receiving adequate follow-up care and receiving enough helpful information for social needs, including food, housing, transportation, and being able to afford care. These are the areas where patients often fall through the cracks, which can affect their ability to adhere to care plans or avoid seeing their condition worsening. Even when patients asked for help with these issues, nearly half never received a referral to a service that could help. 

Relatedly, patients and caregivers said they didn’t get follow-up primary care or specialist appointments set up more than half the time, and 40% said they never received a follow-up call from the skilled nursing facility after discharge. “Post-discharge follow-up calls are considered a best practice that can help identify and address problems early and possibly avoid more serious complications, acute care utilization, and patient and caregiver stress,” the survey authors reported. Taken together, the findings suggest that progress is occurring in improving these transitions from facility to home, but there’s plenty of room for further improvement. 

Interventions that Work

The gaps identified in the survey were the ones that UHF mainly focused on in developing its toolkit and effective interventions. The report includes the interventions implemented at the eight skilled nursing facilities and how various metrics improved. For example, follow-up calls from the facilities to patients improved from 59% to 74% after the interventions described in the toolkit. Further, patients’ understanding of their prescribed medication improved from 57% to 98%, and their understanding of their symptoms and possible problems that could occur at home improved from 70% to 93%.

Unsurprisingly, the report documents the challenges that the pandemic presented in developing the toolkit, testing the interventions, and general patient care transitions. For example, the need to restrict family visitation frequently interfered with the need to meet with caregivers and conduct education and transition planning. The report authors identified four broad areas of lessons learned: the value of process mapping (showing in diagrams the steps of the transition process), standardization of processes, interdisciplinary planning, and early and tailored follow-up contact after discharge. 

The UHF also provides a page of existing resources to improve transitions, some reproduced here from their site. The site also contains resources for specific conditions, including atrial fibrillation, COPD, dementia, heart failure, Parkinson’s disease, stroke, and wound care. Here’s a selection of their resources: 

Care Transitions Toolkits

• Society of Hospital Medicine - Project BOOST Implementation Guide to Improve Care Transition
• AHRQ Care Transitions from Hospital to Home IDEAL Discharge Planning Training

Communication Tools

• RWJF – Discharge Preparation Checklist
• HealthCentric Advisors – Post-Discharge Call Script
• HealthCentric Advisors – 2-Day Follow-up Phone Call Documentation
• HealthCentric Advisors – 30-Day Follow-up Phone Call Documentation

Discharge Checklists

• CMS – Your Discharge Planning Checklist
• RWJF – Discharge Preparation Checklist
• HealthCentric Advisors – My After Nursing Home Care Plan
• AHRQ – IDEAL Discharge Planning Checklist
• SHM Project BOOST - The 8P Screening Tool Identifying Your Patient’s Risk for Adverse Events After Discharge
• HealthCentric Advisors – Re-engineered Discharge for SNFs Checklist

Family Caregiver Tools

• HealthCentric Advisors – Caregiver assessment
• UHF Next Step in Care - Make Sure All of Your Family Member’s Doctors and the Home Care Nurse Know All the over-the-Counter and Herbal Medications Your Family Member Is Taking
• UHF Next Step in Care – Going Home What You Need to Know
• UHF Next Step in Care – Rehab-to-Home Discharge Guide
• UHF Next Step in Care – When Home Care Ends A Family Caregiver’s Guide
• Eric Coleman – Family Caregiver Activation in Transitions (FCAT) Tool

Medication Management Tools

• Eric Coleman – Medication Discrepancy Tool
• UHF Next Step in Care  –  Medication Management Form

Social Needs Screening Tools and Assessment

• Health Leads - Social Needs Screening Toolkit
• CMS – The Accountable Health Communities Health-Related Social Needs Screening Tool

Falls

• CDC – A Home Fall Prevention Checklist for Older Adults
• CDC – Talking about Fall Prevention with Your Patients
• CDC – Family Caregivers Protect Your Loved Ones from Falling
• CDC – MyMobility Plan