Transitions of care involving seniors — especially those with multiple chronic conditions — can be risky.
Despite this, there are a number of methods skilled nursing facilities (SNFs) and other health care organizations can adopt to improve the transition from in-patient care to home for patients and their caregivers.
That’s according to a report released Monday by the United Hospital Fund (UHF), a New York-based health equity nonprofit. The report is the result of UHF’s SNF Learning Collaborative, a two-year partnership with eight New York-based SNFs. The aim of the partnership was to enhance care transitions.
One takeaway for home health providers is the importance of working with SNFs to further strengthen SNF-to-home transitions.
Overall, less than 53% of patients successfully return to their homes or a community-based service following a short stay in a SNF, according to the U.S. Centers for Medicare & Medicaid Services (CMS).
A big part of the reason for this is poor preparation when it comes to care transitions, according to the report.
“Inadequate preparation for transitions frequently places frail and otherwise vulnerable older adults at risk of overuse of acute care services, declining health, permanent SNF residency, and high levels of stress, anxiety and dissatisfaction,” the authors wrote in the report. “For Medicare beneficiaries with multiple chronic conditions, lower socioeconomic status, dual Medicare/Medicaid eligibility, cognitive impairment or limited English proficiency, the risk of poor outcomes is even higher.”
In order to ensure success, SNFs need to play a key role in facilitating care transitions, the authors explain.
One SNF in the collaborative was able to do this by focusing on improving its medication education prior to discharge.
After identifying medication education as one of its weak points, the SNF worked to turn this around by having nurses review medication with patients and caregivers within three days of admission — and again before discharge. Three days later, via follow-up calls, a social worker assessed the patient’s understanding through related questions.
The SNF found that patients’ understanding of medications improved from 60% before the intervention to 94% after.
Another method was centered on improving patients’ education on chronic illness self-management. Home health providers can, no doubt, also play an integral role in deepening patients’ knowledge in this area.
“The SNFs transitional educators adopted the teach-back method to provide chronic illness self-management to patients during their stay,” the authors wrote. “The transitional educators used zone tools, a set of resources designed to aid in patient self-management by helping identify common symptoms, warning signs, and the appropriate patient response, using a simple green, yellow and red color-coding system to help direct patient responses.”
Zone tools were used for chronic pulmonary obstructive disease, diabetes, heart disease, heart failure, kidney health and stroke.
Plus, the SNF used nursing students to help provide virtual education sessions to patients.
“The SNF interventions implemented in our project, and explained in the toolkit, led to marked improvement in our partners’ ability to ensure that patients’ needs were met as they went home,” Joan Guzik, UHF director of quality and efficiency and the report’s lead author, said in a press release.
The other side of the SNF-to-home transitions coin is the rise of SNF-at-home programs over the past couple of years.
“[In-home care providers] have known that keeping people at home typically results in better clinical outcomes,” Leslie Palmer, administrator and clinical director at Josephine at Home, previously told Home Health Care News. “It’s less expensive. And it keeps people out of the hospital. I think what’s different now is we have the opportunity to enhance that concept. Now, we’ve named it ‘SNF-at-home,’ and we’ve formalized operational aspects.”
Companies such as Josephine Caring Community, UnityPoint and others have rolled out SNF-at-home programs as a response to the call for higher acuity care in the home setting.
Companies featured in this article:
