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Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities.

Publication ,  Journal Article
Toles, M; Leeman, J; Colón-Emeric, C; Hanson, LC
Published in: J Appl Gerontol
August 2020

Prior studies have not described strategies for implementing transitional care in skilled nursing facilities (SNFs). As part of the Connect-Home study, we pilot tested the Transition Plan of Care (TPOC) template, an implementation tool that SNF staff used to deliver transitional care. A retrospective chart review was used to describe the impact of the TPOC template on three implementation outcomes: reach to patients, staff adoption of the template, and staff fidelity to the intervention protocol for transition care planning. The template reached 100% of eligible patients (N = 68). Adoption was high, with documentation by four disciplines in 90.6% of patient records (N = 61). Fidelity to the intervention protocol was moderately high, with 73% of documentation that was concordant with the protocol. Our findings suggest an electronic medical record (EMR)-based implementation tool may increase the ability of staff to prepare older adults and their caregivers for self-care at home. Further research is needed to test the efficacy of the protocol on patient outcomes after transitions from SNF to home.

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Published In

J Appl Gerontol

DOI

EISSN

1552-4523

Publication Date

August 2020

Volume

39

Issue

8

Start / End Page

855 / 862

Location

United States

Related Subject Headings

  • Transitional Care
  • Skilled Nursing Facilities
  • Retrospective Studies
  • Nursing Staff
  • Male
  • Humans
  • Home Care Services
  • Health Plan Implementation
  • Gerontology
  • Female
 

Citation

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Toles, M., Leeman, J., Colón-Emeric, C., & Hanson, L. C. (2020). Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities. J Appl Gerontol, 39(8), 855–862. https://doi.org/10.1177/0733464818783689
Toles, Mark, Jennifer Leeman, Cathleen Colón-Emeric, and Laura C. Hanson. “Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities.J Appl Gerontol 39, no. 8 (August 2020): 855–62. https://doi.org/10.1177/0733464818783689.
Toles M, Leeman J, Colón-Emeric C, Hanson LC. Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities. J Appl Gerontol. 2020 Aug;39(8):855–62.
Toles, Mark, et al. “Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities.J Appl Gerontol, vol. 39, no. 8, Aug. 2020, pp. 855–62. Pubmed, doi:10.1177/0733464818783689.
Toles M, Leeman J, Colón-Emeric C, Hanson LC. Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities. J Appl Gerontol. 2020 Aug;39(8):855–862.
Journal cover image

Published In

J Appl Gerontol

DOI

EISSN

1552-4523

Publication Date

August 2020

Volume

39

Issue

8

Start / End Page

855 / 862

Location

United States

Related Subject Headings

  • Transitional Care
  • Skilled Nursing Facilities
  • Retrospective Studies
  • Nursing Staff
  • Male
  • Humans
  • Home Care Services
  • Health Plan Implementation
  • Gerontology
  • Female