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

Publication ,  Conference
Krol, ML; Allen, C; Matters, L; Jolly Graham, A; English, W; White, HK
Published in: J Nurs Care Qual
2019

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.

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Published In

J Nurs Care Qual

DOI

EISSN

1550-5065

Publication Date

2019

Volume

34

Issue

3

Start / End Page

217 / 222

Location

United States

Related Subject Headings

  • Transitional Care
  • Skilled Nursing Facilities
  • Patient Transfer
  • Patient Readmission
  • Nursing
  • Middle Aged
  • Male
  • Humans
  • Hospitals
  • Health Maintenance Organizations
 

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Krol, M. L., Allen, C., Matters, L., Jolly Graham, A., English, W., & White, H. K. (2019). Health Optimization Program for Elders: Improving the Transition From Hospital to Skilled Nursing Facility. In J Nurs Care Qual (Vol. 34, pp. 217–222). United States. https://doi.org/10.1097/NCQ.0000000000000375
Krol, Michael L., Colette Allen, Loretta Matters, Aubrey Jolly Graham, William English, and Heidi K. White. “Health Optimization Program for Elders: Improving the Transition From Hospital to Skilled Nursing Facility.” In J Nurs Care Qual, 34:217–22, 2019. https://doi.org/10.1097/NCQ.0000000000000375.
Krol ML, Allen C, Matters L, Jolly Graham A, English W, White HK. Health Optimization Program for Elders: Improving the Transition From Hospital to Skilled Nursing Facility. In: J Nurs Care Qual. 2019. p. 217–22.
Krol, Michael L., et al. “Health Optimization Program for Elders: Improving the Transition From Hospital to Skilled Nursing Facility.J Nurs Care Qual, vol. 34, no. 3, 2019, pp. 217–22. Pubmed, doi:10.1097/NCQ.0000000000000375.
Krol ML, Allen C, Matters L, Jolly Graham A, English W, White HK. Health Optimization Program for Elders: Improving the Transition From Hospital to Skilled Nursing Facility. J Nurs Care Qual. 2019. p. 217–222.

Published In

J Nurs Care Qual

DOI

EISSN

1550-5065

Publication Date

2019

Volume

34

Issue

3

Start / End Page

217 / 222

Location

United States

Related Subject Headings

  • Transitional Care
  • Skilled Nursing Facilities
  • Patient Transfer
  • Patient Readmission
  • Nursing
  • Middle Aged
  • Male
  • Humans
  • Hospitals
  • Health Maintenance Organizations