title: Transitional care in skilled nursing facilities: a multiple case study.
abstract: Among hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement.
  
  
  
  In this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services.
  
  
  
  Staff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions.
  
  
  
  Organizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care.
authors.affiliation: University of North Carolina at Chapel Hill, School of Nursing, 7460 Carrington Hall, Chapel Hill, NC, 27599, USA. mtoles@email.unc.edu.
authors.forename: Mark
authors.initials: M
authors.lastname: Toles
authors.affiliation: School of Medicine and the Geriatric Research, Education and Clinical Center (GRECC), Durham Veterans Affairs Medical Center, Duke University, DUMC 3469, Durham, NC, 27710, USA.
authors.forename: Cathleen
authors.initials: C
authors.lastname: Colón-Emeric
authors.affiliation: NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Room 341 Fagin Hall, 418 Curie Blvd., Philadelphia, PA, 19104-4217, USA.
authors.forename: Mary D
authors.initials: MD
authors.lastname: Naylor
authors.affiliation: Medical University of South CarolinaCollege of Nursing, Room 508 99 Jonathan Lucas St., Charleston, SC, 29425-1600, USA.
authors.forename: Julie
authors.initials: J
authors.lastname: Barroso
authors.affiliation: University of North Carolina at Chapel Hill, School of Nursing, 7460 Carrington Hall, Chapel Hill, NC, 27599, USA.
authors.forename: Ruth A
authors.initials: RA
authors.lastname: Anderson
mesh_terms: D000368:Aged; D003695:Delivery of Health Care / Q000458:organization & administration; D004636:Emergency Service, Hospital / Q000458:organization & administration; D055318:Evidence-Based Nursing; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007400:Interprofessional Relations; D007902:Length of Stay; D010347:Patient Care Planning; D010348:Patient Care Team; D011446:Prospective Studies; D012866:Skilled Nursing Facilities / Q000458:organization & administration*; D000069341:Transitional Care / Q000458:organization & administration*; D014481:United States
keywords: Older adults; Skilled nursing facilities; Transitional care