Staff interaction strategies that optimize delivery of transitional care in a skilled nursing facility: a multiple case study.

Journal Article (Journal Article)

After hospitalization, more than 1.5 million older adults each year receive postacute care in skilled nursing facilities (SNFs). Transitional care services, designed to prepare older SNF patients (and their family caregivers) for their transitions from an SNF to home, have rarely been studied. Thus, we conducted a longitudinal, multiple case study of transitional care provided in an SNF to explore the care processes and staff interaction strategies that SNF staff members used to optimize delivery of transitional care. Using qualitative data from 89 interviews, 118 field observations, and 70 chart, or document reviews, we observed that transitional care services were not solely formalized processes, but rather were embedded in the interactions among older adult patients, their family caregivers, and members of interdisciplinary care teams. We found, moreover, that staff member interactions with patients and family caregivers increased the capacity of patient care teams for optimizing patient-centered care, information exchange, and coordination of transitional care.

Full Text

Duke Authors

Cited Authors

  • Toles, M; Barroso, J; Colón-Emeric, C; Corazzini, K; McConnell, E; Anderson, RA

Published Date

  • October 2012

Published In

Volume / Issue

  • 35 / 4

Start / End Page

  • 334 - 344

PubMed ID

  • 22929379

Pubmed Central ID

  • PMC3967871

Electronic International Standard Serial Number (EISSN)

  • 1550-5057

Digital Object Identifier (DOI)

  • 10.1097/FCH.0b013e31826666eb


  • eng

Conference Location

  • United States