4 years ago

Connect-Home: Transitional Care of Skilled Nursing Facility Patients and their Caregivers

Josephine Asafu-Adjei, Mark Toles, Laura C. Hanson, Mary D. Naylor, Cathleen Colón-Emeric
Background Older 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. Objective To determine the feasibility and relevance of the Connect-Home transitional care intervention, and to compare preparedness for discharge between comparison and intervention dyads. Design A non-randomized, historically controlled design-enrolling dyads of SNF patients and their family caregivers. Setting Three SNFs in the Southeastern United States. Participants Intervention 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. Intervention The Connect-Home intervention consisted of tools and training for existing SNF staff to deliver transitional care of patient and caregiver dyads. Measurements Feasibility 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). Results The 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). Conclusion Connect-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.

Publisher URL: http://onlinelibrary.wiley.com/resolve/doi

DOI: 10.1111/jgs.15015

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