Health Optimization Program for Elders: Improving the Transition From Hospital to Skilled Nursing Facility.

Conference Paper

BACKGROUND: Individuals discharged from the hospital to skilled nursing facilities (SNFs) experience high rates of unplanned hospital readmission, indicating opportunity for improvement in transitional care. LOCAL PROBLEM: Local physicians providing care in SNFs were not associated with the discharging hospital health care system. As a result, substantive real-time communication between hospital and SNF physicians was not occurring. METHODS: A multidisciplinary team developed and monitored implementation of the Health Optimization Program for Elders (HOPE) to improve patient transitions from acute hospital stay to SNFs. INTERVENTIONS: The HOPE used a nurse practitioner (NP) to identify geriatric syndromes, set patient/caregiver expectations, assess rehabilitation potential, clarify goals of care, and communicate information directly to SNF providers. RESULTS: The intervention was feasible, addressed unmet needs and errors in the SNF transition process, and was associated with lower 30-day readmission rates compared with concurrent patients not enrolled in the HOPE. CONCLUSIONS: An NP-led hospital to SNF transitional care program is a promising means of improving hospital to SNF transitions.

Full Text

Duke Authors

Cited Authors

  • Krol, ML; Allen, C; Matters, L; Jolly Graham, A; English, W; White, HK

Published Date

  • 2019

Published In

Volume / Issue

  • 34 / 3

Start / End Page

  • 217 - 222

PubMed ID

  • 30550492

Electronic International Standard Serial Number (EISSN)

  • 1550-5065

Digital Object Identifier (DOI)

  • 10.1097/NCQ.0000000000000375

Conference Location

  • United States