Transitional care in skilled nursing facilities: a multiple case study
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Toles, Mark, et al. Transitional Care In Skilled Nursing Facilities: a Multiple Case Study. BioMed Central, 2016. https://doi.org/10.17615/2wtz-5f22APA
Toles, M., Colón Emeric, C., Naylor, M., Barroso, J., & Anderson, R. (2016). Transitional care in skilled nursing facilities: a multiple case study. BioMed Central. https://doi.org/10.17615/2wtz-5f22Chicago
Toles, Mark, Cathleen Colón Emeric, Mary D Naylor, Julie Barroso, and Ruth Anderson. 2016. Transitional Care In Skilled Nursing Facilities: a Multiple Case Study. BioMed Central. https://doi.org/10.17615/2wtz-5f22- Creator
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Toles, Mark
- Affiliation: School of Nursing
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Colón-Emeric, Cathleen
- Other Affiliation: School of Medicine and the Geriatric Research, Education and Clinical Center (GRECC), Durham Veterans Affairs Medical Center, Duke University, DUMC 3469, Durham, NC 27710, USA
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Naylor, Mary D
- Other Affiliation: NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Room 341 Fagin Hall, 418 Curie Blvd., Philadelphia, PA 19104-4217, USA
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Barroso, Julie
- Other Affiliation: Medical University of South CarolinaCollege of Nursing, Room 508 99 Jonathan Lucas St., Charleston, SC 29425-1600, USA
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Anderson, Ruth
- Affiliation: School of Nursing
- Abstract
- Abstract Background Among hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement. Methods In this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services. Results Staff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions. Conclusions Organizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care.
- Date of publication
- May 17, 2016
- DOI
- Identifier
- Resource type
- Article
- Rights statement
- In Copyright
- Rights holder
- Toles et al.
- Language
- English
- Bibliographic citation
- BMC Health Services Research. 2016 May 17;16(1):186
- Publisher
- BioMed Central
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