The transition from hospital to skilled nursing facility continues to frequently be rushed and “chaotic,” new research results show. But SNFs are also starting to implement new systems to address the challenges, which one researcher calls an “exciting” area to further explore.
Researchers uncovered some new innovations — and possibly some skullduggery — after interviewing all parties involved, including staffers and family members.
In some cases, hospitals appeared to share inaccurate patient information with nursing facilities, “perhaps in an effort to place more challenging patients,” noted Emily Gadbois, Ph.D., an investigator with Brown University’s School of Public Health and lead author of the study.
“The key findings were that patients felt rushed in making SNF decisions, were not prepared for the transition or educated about their post-acute needs, and experienced chaotic transitions with complications associated with timing and medications,” she said in an email. “Efforts must be made to improve care coordination and information transfer between hospitals and SNF.”
Researchers interviewed nearly 140 staffers from 16 hospitals and 25 SNFs to reach their conclusions. The sample covered eight geographic markets and included almost 100 newly admitted skilled nursing residents who previously lived at home. Both hospital and SNF interviewees expressed similar concerns about transitions.
One major thread among the markets was that providers failed to include patients and their family members in care coordination. Often, patients were given “inadequate notice” that they were being sent to a SNF, and left in the dark about their discharge plan. Inclusion should begin early in the process, the authors write, when providers are picking the post-acute setting.
Gadbois noted that some SNFs have started implementing new patient orientation systems and formal meet-and-greets that helped residents get acclimated, and experience much smoother transitions. One hospital in the South went as far as inviting SNF staff into the institution to assess patients and ensure they have the right staff competencies to treat them. Another in the Northwest has an admissions coordinator hold orientation with patients, going over a to-do list to explain the therapy process and what to expect during their SNF stay.
Gadbois hopes future research will reveal whether these programs are resulting in improved outcomes. “That would be an exciting area to further explore,” she said.
