Improving Care Transitions in Nursing Homes

By Toles, Mark; Young, Heather M. et al. | Generations, Winter 2012 | Go to article overview

Improving Care Transitions in Nursing Homes


Toles, Mark, Young, Heather M., Ouslander, Joseph, Generations


Successful models exist for improving care transitions to and from nursing homes, but more research is needed-as are the will and incentive for change.

Care transitions expose older adults to added risk for medical complications, decreased quality of life, and overuse of acute healthcare services (National Transitions of Care Coalition, 2010). As illustrated in Figure 1 on page 79, the rates and types of care transitions in nursing homes are shaped by the diverse needs, preferences, and health trajectories of older adults. In some instances, residents require only short stays with rapid transitions to home; in others, residents enter nursing homes, experience acute changes in health, and transition to and from emergency departments or hospitals before returning to the nursing home or returning to their own home.

Though still in the early development stages, a range of new strategies has been designed to prevent avoidable care transitions in nursing homes and to ensure the coordination and continuity of care during transitions. This article proposes a model that describes goals and new strategies for supporting older adults and their family caregivers during three common care transitions in nursing homes.

Nursing Home Demography, Trends, and Care Transitions

Two demographic patterns in nursing homes complicate the goal of ensuring effective care transitions-shorter lengths of stay and greater health acuity. In 2009, 3.3 million residents received care in nearly 16,000 U.S. nursing homes. Unlike in the past, when people remained in nursing homes for years, most people today enter nursing homes for short stays that usually last no more than one to three months (see Figure 2, page 79). For example, in Minnesota, the mean length of stay was 248 days (eight months), while the median length of stay was 27.5 days (Minnesota Department of Health, 2012). The task of managing care transitions is now an expected component of nursing home services.

Older adults also now enter nursing homes with increasingly acute health conditions, which means they are more vulnerable to poor health and quality of life outcomes. As a group, nursing home residents have a median age of 85 years. They are often dependent upon caregivers for three or more activities of daily living, and have six or more chronic health conditions and some degree of cognitive impairment.

The most common transition, from hospital to nursing home, requires intensive medical and nursing intervention at time of admission. Moreover, residents and families now delay nursing home admissions until health conditions are advanced and professional assistance is required to manage geriatric syndromes, such as falls and incontinence. Thus, nursing home residents are highly vulnerable to harm from poorly executed care transitions, including inadequate communication of critical information from the hospital, medication errors, omissions, delays in follow-up diagnostic tests and treatments, and repeated hospitalizations.

A Conceptual Model of Care Transitions in Nursing Homes

The fundamental goal of those assisting older adults during care transitions is to promote safe and person-centered transitions that are most likely to achieve resident and family caregiver goals without complications (American Medical Directors Association, 2010). The question arises, then, what can be done about care transitions in nursing homes? How can they be made safer and more effective, person and family-centered, timely, efficient, and equitable?

Although a great deal more experimentation is needed to answer these questions fully, we propose the following three goals and related strategies for improving the quality of care transitions in nursing homes:

* Starting at the time of admission, establish responsive care teams to focus care on the needs and preferences of residents and families;

* During nursing home stays, enhance resources to identify, evaluate, and manage acute changes in health to reduce preventable hospital transfers; and,

* Enhance residents' and family caregivers' capacity to coordinate and continue care at home to reduce medical complications after transition from the nursing home to home. …

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