• Mark Toles, Cathleen Colón-Emeric, Mary D Naylor, Josephine Asafu-Adjei, and Laura C Hanson.
• University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
• J Am Geriatr Soc. 2017 Oct 1; 65 (10): 2322-2328.

BackgroundOlder adults that transfer from skilled nursing facilities (SNF) to home have significant risk for poor outcomes. Transitional care of SNF patients (i.e., time-limited services to ensure coordination and continuity of care) is poorly understood.ObjectiveTo determine the feasibility and relevance of the Connect-Home transitional care intervention, and to compare preparedness for discharge between comparison and intervention dyads.DesignA non-randomized, historically controlled design-enrolling dyads of SNF patients and their family caregivers.SettingThree SNFs in the Southeastern United States.ParticipantsIntervention dyads received Connect-Home; comparison dyads received usual discharge planning. Of 173 recruited dyads, 145 transferred to home, and 133 completed surveys within 3 days of discharge.InterventionThe Connect-Home intervention consisted of tools and training for existing SNF staff to deliver transitional care of patient and caregiver dyads.MeasurementsFeasibility was assessed with a chart review. Relevance was assessed with a survey of staff experiences using the intervention. Preparedness for discharge, the primary outcome, was assessed with Care-Transitions Measure-15 (CTM-15).ResultsThe intervention was feasible and relevant to SNF staff (i.e., 96.9% of staff recommended intervention use in the future). Intervention dyads, compared to comparison dyads, were more prepared for discharge (CTM-15 score 74.7 vs 65.3, mean ratio 1.16, 95% CI: 1.08, 1.24).ConclusionConnect-Home is a promising transitional care intervention for older patients discharged from SNF care. The next step will be to test the intervention using a cluster randomized trial, with patient outcomes including re-hospitalization.© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

12 keywords...

hide…