Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities. (August 2020)

• Record Type: Journal Article
• Authors: Toles, Mark; Leeman, Jennifer; Colón-Emeric, Cathleen; Hanson, Laura C.
• Is Part Of: Journal of applied gerontology. Volume 39:Number 8(2020)
• Page Start: 855
• Page End: 862
• Publication Date: 2020-08
• Subjects: transitional care -- care planning template -- skilled nursing facilities; Gerontology -- Periodicals; 362.6
• DOI: 10.1177/0733464818783689
• Languages: English
• ISSNs: 0733-4648

Abstract

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.