Influence of a Transitional Care Clinic on Subsequent 30-Day Hospitalizations and Emergency Department Visits in Individuals Discharged from a Skilled Nursing Facility

2012 ◽  
Vol 61 (1) ◽  
pp. 137-142 ◽  
Author(s):  
Hae K. Park ◽  
Laurence G. Branch ◽  
Tatjana Bulat ◽  
Bavna B. Vyas ◽  
Cynthia P. Roever
Keyword(s):  
Emergency Department ◽  
Transitional Care ◽  
Skilled Nursing Facility ◽  
Emergency Department Visits ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Care Clinic

Progressive Mobility As a Team Effort in Transitional Care

2015 ◽  
Vol 35 (3) ◽  
pp. 62-68 ◽  
Author(s):  
Margaret M. Ecklund ◽  
Jill W. Bloss
Keyword(s):  
Hospital Readmission ◽  
Transitional Care ◽  
Interdisciplinary Collaboration ◽  
Skilled Nursing Facility ◽  
Care Program ◽  
Care Needs ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Core Culture ◽  
The Continuum

With changing health care, progressive care nurses are working in diverse practice settings to meet patient care needs. Progressive care is practiced along the continuum from the intensive care unit to home. The benefits of early progressive mobility are examined with a focus on the interdisciplinary collaboration for care in a transitional care program of a skilled nursing facility. The program’s goals are improved functional status, self-care management, and home discharge with reduced risk for hospital readmission. The core culture of the program is interdisciplinary collaboration and team partnership for care of patients and their families.

The effects of telehealth use for post-acute rehabilitation patient outcomes

2016 ◽  
Vol 24 (3) ◽  
pp. 179-184 ◽  
Author(s):  
Stephanie A Hicks ◽  
Verena R Cimarolli
Keyword(s):  
Cognitive Functioning ◽  
Patient Outcomes ◽  
Skilled Nursing Facility ◽  
Functional Independence ◽  
Emergency Department Visits ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Rehabilitation Care ◽  
Acute Rehabilitation ◽  
The Impact

Introduction Previous research has shown that home telehealth services can reduce hospitalisations and emergency department visits and improve clinical outcomes among older adults with chronic conditions. However, there is a lack of research on the impact of telehealth (TH) use on patient outcomes in post-acute rehabilitation settings. The current study examined the effects of TH for post-acute rehabilitation patient outcomes (i.e. discharge setting and change in functional independence) when controlling for other factors (e.g. cognitive functioning). Methods For this retrospective study, electronic medical records (EMRs) of 294 patients who were discharged from a post-acute rehabilitation unit at a skilled nursing facility were reviewed. Only patients with an admitting condition of a circulatory disease based on ICD-9 classification were included. Main EMR data extracted included use of TH, cognitive functioning, admission and discharge functional independence, and discharge setting (returning home vs. returning to acute care/re-hospitalisation). Results Results from a regression analysis showed that although TH use was unrelated to post-acute rehabilitation care transition, it was significantly related to change in functional independence. Patients who used TH during their stay had significantly more improvement in functional independence from admission to discharge when compared to those who did not use TH. Discussion Findings indicate that TH use during post-acute rehabilitation has the potential to improve patient physical functioning.

scholarly journals Connect-Home: Transitional Care of Skilled Nursing Facility Patients and their Caregivers

2017 ◽  
Vol 65 (10) ◽  
pp. 2322-2328 ◽  
Author(s):  
Mark Toles ◽  
Cathleen Colón-Emeric ◽  
Mary D. Naylor ◽  
Josephine Asafu-Adjei ◽  
Laura C. Hanson
Keyword(s):  
Transitional Care ◽  
Skilled Nursing Facility ◽  
Nursing Facility ◽  
Skilled Nursing

Impact of Comprehensive Nurse-Managed Transitional Care

2001 ◽  
Vol 10 (3) ◽  
pp. 295-313 ◽  
Author(s):  
Ruth M. Tappen ◽  
Rosemary F. Hall ◽  
Susan L. Folden
Keyword(s):  
Daily Living ◽  
Transitional Care ◽  
Comparison Group ◽  
Skilled Nursing Facility ◽  
Design Data ◽  
Nursing Facility ◽  
Care Environment ◽  
Skilled Nursing ◽  
Quasi Experimental

The purpose of this study was to test the effectiveness of nurse-managed transitional care on the quality of care and functional ability of individuals following discharge from subacute units. Registered nurses employed on subacute units in a skilled nursing facility provided the nurse-managed transitional care. Using a quasi-experimental design, data were collected on admission to the subacute unit, at the time of discharge, 1 week following discharge, and 3 months following discharge on 242 treatment and comparison participants. The treatment group participants' overall function and quality of the care environment were significantly higher than the comparison group at 1 week and 3 months following discharge. Participants did not differ significantly on basic activities of daily living or number of readmissions.

scholarly journals Transitional Care Outcomes in Veterans Receiving Post‐Acute Care in a Skilled Nursing Facility

2019 ◽  
Vol 67 (9) ◽  
pp. 1820-1826 ◽  
Author(s):  
Robert E. Burke ◽  
Anne Canamucio ◽  
Thomas J. Glorioso ◽  
Anna E. Barón ◽  
Kira L. Ryskina
Keyword(s):  
Acute Care ◽  
Transitional Care ◽  
Skilled Nursing Facility ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Care Outcomes ◽  
Post Acute Care

scholarly journals TRANSITIONAL CARE OUTCOMES IN VETERANS RECEIVING POST-ACUTE CARE IN A SKILLED NURSING FACILITY

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S732-S732
Author(s):  
Robert Burke ◽  
Anne Canamucio ◽  
Thomas Glorioso ◽  
Anna Baron ◽  
Kira Ryskina
Keyword(s):  
Acute Care ◽  
Transitional Care ◽  
Adverse Outcome ◽  
Skilled Nursing Facility ◽  
Adverse Outcomes ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Episodes Of Care ◽  
Va Hospitals ◽  
Post Acute Care

Abstract More than 200,000 Veterans transition between hospital and skilled nursing facility (SNF) annually. Capturing outcomes of these transitions has been challenging because older adult Veterans receive care at VA and non-VA hospitals, and four different kinds of SNFs: VA-owned and -operated Community Living Centers (CLCs), VA-contracted community nursing homes (CNHs), State Veterans Homes (SVHs), and non-VA community SNFs. We used a novel data source which concatenates VA, Medicare, and Medicaid data into longitudinal episodes of care for Veterans, to calculate the rate of adverse outcomes associated with the transition from hospital to SNF in all enrolled Veterans age 65 and older undergoing this transition 2012-2014. The composite primary outcome included Emergency Department (ED) visits, rehospitalizations, and mortality (not in the context of hospice) within 7 days of hospital discharge to SNF. We used multivariable logistic regression to adjust for Veteran and hospital characteristics and hospital random effects. In the 388,339 Veterans discharged from 1502 hospitals in our sample, we found more than 4 in 5 Veteran transitions (81.7%) occurred entirely outside the VA system. The overall 7-day outcome rate was 10.7%. After adjustment, VA hospitals had lower adverse outcome rates than non-VA hospitals (OR 0.80, 95% CI 0.74-0.86). VA hospital-CLC transitions had the lowest adverse outcome rates; in comparison, non-VA hospital-CNH (OR 2.51, 95% CI 2.09-3.02) and non-VA hospital-CLC (OR 2.25, 95% CI 1.81-2.79) had the highest rates. These findings raise important questions about the VA’s role as a major provider and payer of post-acute care in SNF.

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