title: Staff interaction strategies that optimize delivery of transitional care in a skilled nursing facility: a multiple case study.
abstract: After hospitalization, more than 1.5 million older adults each year receive postacute care in skilled nursing facilities (SNFs). Transitional care services, designed to prepare older SNF patients (and their family caregivers) for their transitions from an SNF to home, have rarely been studied. Thus, we conducted a longitudinal, multiple case study of transitional care provided in an SNF to explore the care processes and staff interaction strategies that SNF staff members used to optimize delivery of transitional care. Using qualitative data from 89 interviews, 118 field observations, and 70 chart, or document reviews, we observed that transitional care services were not solely formalized processes, but rather were embedded in the interactions among older adult patients, their family caregivers, and members of interdisciplinary care teams. We found, moreover, that staff member interactions with patients and family caregivers increased the capacity of patient care teams for optimizing patient-centered care, information exchange, and coordination of transitional care.
authors.affiliation: Duke University, School of Nursing, DUMC 3322, Durham, NC 27710, USA. mark.toles@duke.edu
authors.forename: Mark
authors.initials: M
authors.lastname: Toles
authors.forename: Julie
authors.initials: J
authors.lastname: Barroso
authors.forename: Cathleen
authors.initials: C
authors.lastname: Colón-Emeric
authors.forename: Kirsten
authors.initials: K
authors.lastname: Corazzini
authors.forename: Eleanor
authors.initials: E
authors.lastname: McConnell
authors.forename: Ruth A
authors.initials: RA
authors.lastname: Anderson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D001294:Attitude to Health; D003266:Continuity of Patient Care / Q000458:organization & administration*; D003695:Delivery of Health Care / Q000379:methods*; D017598:Efficiency, Organizational; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008137:Longitudinal Studies; D008297:Male; D009723:Nurse-Patient Relations; D019982:Organizational Case Studies; D016134:Organizational Policy; D010043:Outcome and Process Assessment, Health Care / Q000379:methods*; D010342:Patient Acceptance of Health Care; D010348:Patient Care Team / Q000458:organization & administration; D036301:Qualitative Research; D012866:Skilled Nursing Facilities; D015144:Southeastern United States; D000078329:Workforce; D014947:Wounds and Injuries / Q000523:psychology / Q000628:therapy