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Returning Home Safely

Mark Toles, PhD, RN | February 1, 2018
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The Case

A 72-year-old man was admitted to the hospital after a fall at home resulting in a right humerus fracture and shoulder dislocation, as well as other injuries including a right knee contusion. During his admission, the patient underwent right shoulder reduction surgery with plan to keep his arm in a sling until reassessment in 1 month. Given the extent of his injuries and the need for ongoing physical therapy, the plan was made to admit the patient to a skilled nursing facility (SNF) for continued rehabilitation.

The patient lived alone and had little social support. His primary care physician (PCP) suspected that the patient might have dementia, and the results of a Montreal Cognitive Assessment and Kohlman Evaluation of Living Skills assessment performed during the hospitalization raised concerns about the patient's ability to continue to live independently in the community. The hospital's social worker started the process of applying for In-Home Supportive Services and Meals on Wheels, and referred the patient to a home care agency to provide home physical therapy and home nursing visits. However, the final arrangements for these services could not be completed before the patient was discharged, so the trauma team communicated these recommendations to the patient's PCP and the SNF in their discharge summary.

The patient was discharged home from the SNF after a 4-week stay. Three days later, his neighbor brought him to the clinic for an urgent appointment with his PCP. The patient appeared distressed and was complaining of right shoulder pain. His arm remained in a sling, and he was unclear about his medication regimen. His neighbor reported that the patient had not left his apartment since being discharged from the SNF because he was having difficulty climbing the stairs, and he appeared to lack access to food, medications, or transportation to his appointments. The PCP had not received any communication from the SNF about the patient's discharge.

Fortunately, the clinic's social worker followed up on the prior referrals and arranged a home nursing visit and transportation to future appointments. The neighbor also agreed to help with obtaining the patient's medications. The patient did not need to be readmitted to the hospital and was able to stay at home, but the PCP felt frustrated that the patient had not had a better discharge plan.

The Commentary

by Mark Toles, PhD, RN

Every year in the United States, nearly 2 million older adults complete a hospital stay and transfer to one of more than 10,000 skilled nursing facilities (SNFs), where they use the Medicare SNF benefit for postacute care and rehabilitation.(1) During the course of routine care, SNF staff provide discharge planning to support patients' care at home. As illustrated in this case, SNF discharge planning frequently lacks key staff and caregiver input, detailed plans for managing illness at home, and adequate transfer of information to community providers.(2) Thus, it is not surprising that many patients experience adverse events after discharge to home. A recent study found that half of SNF patients who were discharged to home were rehospitalized, visited an emergency department, or died within 90 days.(3)

Transitional care is a promising approach to ensure patients return home safely. It is defined as "time-limited services designed to ensure health care continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients."(4) The efficacy of transitional care in SNFs is not known.(5) However, when a similar strategy is deployed in hospitals, it is associated with patients' improved preparedness for discharge and reduced rates of rehospitalization.(6) Recent findings from observational research have identified a toolset that can be used to implement transitional care in SNFs and provide patients with skills, supports, and resources for a safe transition home.(7-10)

Skilled nursing facility patients are a frail, medically complex population, in whom the toll of serious acute illness is frequently compounded by functional losses and chronic conditions. To develop a transition plan of care addressing this broad array of needs, SNF nurses, social workers, and rehabilitation therapists require specialized tools and training. One essential tool is an electronic health record (EHR) template that (i) embeds transition planning into the SNF's routines of care and (ii) delineates the domains of a complete transition plan of care, such as medications, advanced care plans, follow-up providers, mobility, self-care, and caregiver roles. Combined with a checklist that staff members use to develop transition plans, the EHR template guides staff on care processes and documentation required for each transition planning domain. For example, in the medications planning domain, the checklist guides staff to document instructions about new or recently changed medications, loading pill boxes, and using PRN (i.e., as needed) or pain medications. Further, the EHR template facilitates documenting a transition plan of care in one place, thereby presenting a unified overall plan to patients and their caregivers. While one can imagine compiling each of these tools in a paper-based system, the EHR template plays an important role by creating a focal point for transitional care and ensuring a complete plan to continue care at home. (7,9) In SNFs that lack an EHR system, elements of this process should be incorporated with staff training for using revised, paper-based forms to document a detailed and complete transition plan for care at home.

Managing time constraints and uncertainty about patient discharge in SNFs requires careful timing of the interactions between staff, individual patients, and their caregivers.(11) As staff deliver transitional care, an intervention schedule can help time and organize these interactions. First, during the initial 1 to 2 weeks of a patient's admission, staff collaborate with the patient and caregiver to create a transition plan of care. This plan should be completed early because ample time is needed to implement the plan before patients go home.(12) As this case illustrates, failure to implement plans well before discharge increases the risk of adverse events. For example, recuperating patients may discover they are simply too tired to manage care independently.

Second, during the last 2 to 3 days of a patient's admission, staff should verify the accuracy of written transition plans; for example, whether new medications have been ordered or rehabilitation plans have been revised. With the verified plan, staff are prepared to (i) use the transition plan in final discharge teaching; (ii) give a printed copy to the patient for use at home; and (iii) transmit the transition plan to follow-up community providers.(12)

Finally, during the first days or weeks after the patient returns home, an intervention schedule marks the timing of postdischarge contact with patients, such as a 72-hour window for calling patients at home.(12) Follow-up contact is essential to reinforce the plan and triage emerging problems in care. In summary, transitional care in SNFs is more than a set of evidence-based care processes. To reliably ensure safety, it also must include organizational support for this care, such as an EHR template for creating transition plans of care and an intervention schedule for timing when elements of transitional care are delivered. A common barrier to implementing transitional care in SNFs is the scarcity of clinical staff for delivering services and supports. This challenge can be met by integrating transitional care in routine activities, such as educating caregivers in rehabilitation therapy sessions and involving nurses who complete patient admission assessments in the care planning process.

More broadly, physicians and other professionals across health care systems will improve the effectiveness of SNF-based transitional care only by consistently addressing the needs of family caregivers.(13,14) Family caregivers need training to understand strategies for managing the patient's serious illness at home, alternatives to hospital care, fall prevention, home-based rehabilitation, and meaningful activities for patients over the long course of illness at home.(15) This process begins at the time of admission, when SNF team members have opportunities to welcome caregivers. As soon as possible, staff should ask questions about caregivers' expectations, learn strengths and limitations for supporting the patient at home, and schedule appointments so that caregivers can participate in planning and education activities in the SNF.(7,9) Because family caregivers provide so much patient care at home, cultivating their participation in the SNF is the foundation for promoting patient safety.

This case described preventable circumstances of an isolated, cognitively impaired older adult returning home with new orthopedic injuries and virtually no plan for managing activities of daily living or medical care at home. The case did not include any details of discharge planning or transitional care provided in the SNF. However, the case suggests how even rudimentary services and supports (provided by social workers in a hospital and primary care clinic) activated a safety net for the patient's convalescence at home. Thus, the case highlights the significance of improving patient and caregiver capacity for self-care after transferring from SNFs to home.

Take-Home Points

  • Patients treated in skilled nursing facilities are at high risk for rehospitalization, emergency department use, and death after returning home.
  • Interdisciplinary teams of nurses, social workers, and rehabilitation therapists are ideally positioned to deliver transitional care, prepare patients and caregivers for discharge, and prevent poor outcomes such as rehospitalization.
  • Staff in skilled nursing facilities are more likely to be reliable providers of high-quality transitional care when they are armed with electronic health record tools and other organizational supports.
  • Efforts to improve transitional care should focus on family caregivers, who assume the largest share of patient care after discharge.

Mark Toles, PhD, RN Assistant Professor School of Nursing University of North Carolina at Chapel Hill


1. Report to the Congress: Medicare Payment Policy. Washington, DC: Medicare Payment Advisory Commission; March 2016. [Available at]

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3. Toles M, Anderson RA, Massing M, et al. Restarting the cycle: incidence and predictors of first acute care use after nursing home discharge. J Am Geriatr Soc. 2014;62:79-85. [go to PubMed]

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7. Berkowitz RE, Fang Z, Helfand BK, Jones RN, Schreiber R, Paasche-Orlow MK. Project ReEngineered Discharge (RED) lowers hospital readmissions of patients discharged from a skilled nursing facility. J Am Med Dir Assoc. 2013;14:736-740. [go to PubMed]

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9. Toles M, Colón-Emeric C, Naylor MD, Asafu-Adjei J, Hanson LC. Connect-Home: transitional care of skilled nursing facility patients and their caregivers. J Am Geriatr Soc. 2017;65:2322-2328. [go to PubMed]

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13. Byrne K, Orange JB, Ward-Griffin C. Care transition experiences of spousal caregivers: from a geriatric rehabilitation unit to home. Qual Health Res. 2011;21:1371-1387. [go to PubMed]

14. Levine C, Halper D, Peist A, Gould DA. Bridging troubled waters: family caregivers, transitions, and long-term care. Health Aff (Millwood). 2010;29:116-124. [go to PubMed]

15. Schultz R, Eden J, eds. Families Caring for An Aging America. Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2016. [go to PubMed]

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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