Gaps in Hospital and Skilled Nursing Facility Responsibilities During Transitions of Care: a Comparison of Hospital and SNF Clinicians' Perspectives

Leveraging and learning from the long COVID experience: Translating telerehabilitation into practice

BACKGROUND

Telerehabilitation, or the delivery of rehabilitation services through telehealth platforms, has existed since the late 1990 s. Telerehabilitation was characterized by unprecedented, exponential growth at the beginning of the novel coronavirus-2019 (COVID-19) pandemic. Medical systems sought to reduce the likelihood of disease transmission by using telerehabilitation to limit physical proximity during routine care. This dramatic change in how medical care was delivered forced many professions to adapt processes and practices. Following the change, debates sparked regarding the best path to move forward for the betterment of patients, clinicians, systems, and society. Long COVID has emerged as a complex chronic health condition arising from COVID-19. The unique needs and dynamic disease process of Long COVID has incentivized medical systems to create equitable ways for patients to safely access interdisciplinary care.

OBJECTIVES

The purpose of this commentary is to describe what medical systems must consider when deploying high-quality telerehabilitation to deliver rehabilitation through asynchronous (e.g., text, portal) and synchronous modalities (e.g., phone or video). We highlight lessons learned to help guide decision-makers on key actions to support their patients and clinicians.

METHODS

Not applicable.

RESULTS

Not applicable.

CONCLUSIONS

Key action steps from our lessons learned may be used to address complex chronic health conditions such as Long COVID and prepare for future challenges that may disrupt medical systems.

An Interdisciplinary Videoconference to Improve Transitions of Care and Reduce Readmission, Cost, and Post-Acute Length of Stay in a Teaching and Community Hospital

OBJECTIVES

Coordination of care across health care settings is needed to ensure safe patient transfers. We examined the effects of the ECHO-Care Transitions program (ECHO-CT) on readmissions, skilled nursing facility (SNF) length of stay (LOS), and costs.

DESIGN

This is a prospective cohort study evaluating the ECHO-CT program. The intervention consisted of weekly 90-minute teleconferences between hospital and SNF-based teams to discuss the care of recently discharged patients.

SETTING AND PARTICIPANTS

The intervention occurred at one small community hospital and 7 affiliated SNFs and 1 large teaching hospital and 11 associated SNFs between March 23, 2019, and February 25, 2021. A total of 882 patients received the intervention.

METHODS

We selected 13 hospitals and 172 SNFs as controls. Specific hospital-SNF pairings within the intervention and control groups are referred to as hospital-SNF dyads. Using Medicare claims data for more than 10,000 patients with transfers between these hospital-SNF dyads, we performed multivariable regression to evaluate differences in 30-day rehospitalization rates, SNF lengths of stay, and SNF costs between patients discharged to intervention and control hospital-SNF dyads. We split the post period into pre-COVID and COVID periods and ran models separately for the small community and large teaching hospitals.

RESULTS

There was no significant difference-in-differences among intervention compared to control facilities during either post-acute care period for any of the outcomes.

CONCLUSIONS AND IMPLICATIONS

Although video-communication of care plans between hospitalists and post-acute care clinicians makes good clinical sense, our analysis was unable to detect significant reductions in rehospitalizations, SNF lengths of stay, or SNF Medicare costs. Disruption of the usual processes of care by the COVID pandemic may have played a role in the null findings.

Hospitalists Improving Transitions of Care Through Virtual Collaborative Rounding with Skilled Nursing Facilities-the HiToC SNF Study

BACKGROUND

Over one in five Medicare patients discharged to skilled nursing facilities (SNFs) are re-hospitalized within 30 days of discharge. Poor communication between the hospital and SNF upon hospital discharge is frequently cited as the most common cause of readmission.

AIM

The goal of this program was to assess the ability of a weekly post-discharge hospitalist led virtual rounding program to augment the written discharge summary sent to SNFs.

SETTING

Two academic hospitals and six SNFs in Baltimore, MD.

PARTICIPANTS

Hospitalists and medical directors or directors of nursing from the partner SNF.

PROGRAM DESCRIPTION

During weekly encounters, the hospitalist and SNF providers discussed the clinical status, discharge medications, treatment plan, and follow-up care of all discharged patients. The intervention took place from July 2021 to December 2021.

PROGRAM EVALUATION

During the study, 544 patients were discussed in a post-discharge virtual encounter. After the discussions, hospitalists identified clinically significant errors in 124 discharge summaries. A survey of participating hospitalists and SNF medical and nursing leadership indicated the intervention was thought to improve care transitions.

DISCUSSION

Our innovation was successful in identifying errors in discharge summaries and was thought to improve the transition of care by participating SNF and hospitalist providers.

Perspectives of acute, post-acute, physician and community support providers on community collaborative efforts to improve transitions of care

BACKGROUND

Transitional care (TC) involves multiple organizations as patients transition from hospitals. Collaboration to reduce readmissions has been encouraged by government initiatives. As part of Project ACHIEVE, a comparative TC study, we sought provider perspectives on TC improvement efforts.

METHODS

We aimed to identify perceived problems that drove improvement efforts, influences on interventions implemented, facilitators or barriers to desired outcomes, and sustainability. Investigators interviewed 63 representatives from collaborative improvement efforts across 13 states in 2015. Directed content analysis was performed, with inductive coding as insights emerged. Data was also analyzed for differences in participant perceptions, such as the organization represented, geographic characteristics, and source of funding for interventions.

RESULTS

Participants in semi-structured interviews included physicians, nurses, care navigators, and administrators from hospitals, nursing facilities, community-based organizations, and medical practices. Participants reported that changing reimbursement practices and readmissions penalties drove TC efforts, and common problems they sought to address included insufficient inter-provider communication, medication management, and challenges related to chronic condition management. Solutions implemented were often adapted according to community and setting characteristics and population factors. Findings also suggest differences in the types of interventions implemented according to funding sources, which also impacted the ability to sustain these interventions.

CONCLUSIONS

Cross-site collaboration, communication, and partnership among stakeholders is essential to effective transitional care. Collaboration led to shared understanding among stakeholders of health care and support services available in the community. Coalition-based work also facilitated trust among partners which led to expansion and sustainment of TC efforts. Unmet social needs of patients are a barrier.

IMPLICATIONS

Opportunities exist for increased and improved collaboration among clinical providers with community-based and social services organizations. Increased involvement of primary care providers in such collaborations would improve communication with both the patient and involved providers. Communities with external funding were more likely to implement evidence-based interventions, while those relying on institutional support addressed identified problems with more targeted interventions.

Using comprehensive geriatric assessment for older adults undertaking a facility-based transition care program to evaluate functional outcomes: a feasibility study

BACKGROUND

The study aimed to evaluate the feasibility of using a comprehensive geriatric assessment (CGA) in a residential transition care setting to measure older adults' functional outcomes.

METHODS

A convenience sample of older adults (n = 10) and staff (n = 4) was recruited. The feasibility of using assessment tools that comprise a CGA to comprehensively measure function in physical, cognitive, social and emotional domains was evaluated pre- and post-rehabilitation.

RESULTS

10 older adults (mean ± SD age = 78.9 ± 9.1, n = 6 male) completed a CGA performed using assessments across physical, cognitive, social and emotional domains. The CGA took 55.9 ± 7.3 min to complete. Staff found CGA using the selected assessment tools to be acceptable and suitable for the transition care population. Older adults found the procedure to be timely and 60% found the assessments easy to comprehend. Participating in CGA also assisted older adults in understanding their present state of health. The older adults demonstrated improvements across all assessed domains including functional mobility (de Morton Mobility Index; baseline 41.5 ± 23.0, discharge 55.0 ± 24.0, p = 0.01) and quality of life (EQ-5D-5L; baseline 59.0 ± 21.7, discharge 78.0 ± 16.0, p < 0.01).

CONCLUSIONS

Incorporating CGA to evaluate functional outcomes in transition care using a suite of assessment tools was feasible and enabled a holistic assessment.

Written discharge communication of diagnostic and decision-making information for persons living with dementia during hospital to skilled nursing facility transitions

Hospital-to-skilled nursing facility (SNF) transitions constitute a vulnerable point in care for people with dementia and often precede important care decisions. These decisions necessitate accurate diagnostic/decision-making information, including dementia diagnosis, power of attorney for health care (POAHC), and code status; however, inter-setting communication during hospital-to-SNF transitions is suboptimal. This retrospective cohort study examined omissions of diagnostic/decision-making information in written discharge communication during hospital-to-SNF transitions. Omission rates were 22% for dementia diagnosis, 82% and 88% for POAHC and POAHC activation respectively, and 70% for code status. Findings highlight the need to clarify and intervene upon causes of hospital-to-SNF communication gaps.