Health Optimization Program for Elders: Improving the Transition From Hospital to Skilled Nursing Facility.
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.
Duke Scholars
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- Transitional Care
- Skilled Nursing Facilities
- Patient Transfer
- Patient Readmission
- Nursing
- Middle Aged
- Male
- Humans
- Hospitals
- Health Maintenance Organizations
Citation
Published In
DOI
EISSN
Publication Date
Volume
Issue
Start / End Page
Location
Related Subject Headings
- Transitional Care
- Skilled Nursing Facilities
- Patient Transfer
- Patient Readmission
- Nursing
- Middle Aged
- Male
- Humans
- Hospitals
- Health Maintenance Organizations