Cognitive Biases Influence Decision-Making Regarding Postacute Care in a Skilled Nursing Facility

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

BACKGROUND

Adverse outcomes are common in transitions from hospital to skilled nursing facilities (SNFs). Gaps in transitional care processes contribute to these outcomes, but it is unclear whether hospital and SNF clinicians have the same perception about who is responsible for filling these gaps in care transitions.

OBJECTIVE

We sought to understand the perspectives of hospital and SNF clinicians on their roles and responsibilities in transitional care processes, to identify areas of congruence and gaps that could be addressed to improve transitions.

DESIGN

Semi-structured interviews with interdisciplinary hospital and SNF providers.

PARTICIPANTS

Forty-one clinicians across 3 hospitals and 3 SNFs including nurses (8), social workers (7), physicians (8), physical and occupational therapists (12), and other staff (6).

APPROACH

Using team-based approach to deductive analysis, we mapped responses to the 10 domains of the Ideal Transitions of Care Framework (ITCF) to identify areas of agreement and gaps between hospitals and SNFs.

KEY RESULTS

Although both clinician groups had similar conceptions of an ideal transitions of care, their perspectives included significant gaps in responsibilities in 8 of the 10 domains of ITCF, including Discharge Planning; Complete Communication of Information; Availability, Timeliness, Clarity and Organization of Information; Medication Safety; Educating Patients to Promote Self-Management; Enlisting Help of Social and Community Supports; Coordinating Care Among Team Members; and Managing Symptoms After Discharge.

CONCLUSIONS

As hospitals and SNFs increasingly are held jointly responsible for the outcomes of patients transitioning between them, clarity in roles and responsibilities between hospital and SNF staff are needed. Improving transitions of care may require site-level efforts, joint hospital-SNF initiatives, and national financial, regulatory, and technological fixes. In the meantime, building effective hospital-SNF partnerships is increasingly important to delivering high-quality care to a vulnerable older adult population.

How Context Influences Hospital Readmissions from Skilled Nursing Facilities: A Rapid Ethnographic Study

INTRODUCTION

Improving hospital discharge processes and reducing adverse outcomes after hospital discharge to skilled nursing facilities (SNFs) are gaining national recognition. However, little is known about how the social-contextual factors of hospitals and their affiliated SNFs may influence the discharge process and drive variations in patient outcomes. We sought to categorize contextual drivers that vary between high- and low-performing hospitals in older adult transition from hospitals to SNFs.

DESIGN

To identify contextual drivers, we used a rapid ethnographic approach with interviews and direct observations of hospital and SNF clinicians involved in discharging patients. We conducted thematic analysis to categorize contextual factors and compare differences in high- and low-performing sites.

SETTING AND PARTICIPANTS

We stratified hospitals on 30-day hospital readmission rates from SNFs and used convenience sampling to identify high- and low-performing sites and associated SNFs. The final sample included 4 hospitals (n = 2 high performing, n = 2 low performing) and affiliated SNFs (n = 5) with 148 hours of observations.

MEASURES

Central themes related to how contextual factors influence variations in high- and low-performing hospitals.

RESULTS

We identified 3 main contextual factors that differed across high- and low-performing hospitals and SNFs: team dynamics, patient characteristics, and organizational context. First, we observed high-quality communication, situational awareness, and shared mental models among team members in high-performing sites. Second, the types of patients cared for at high-performing hospitals had better insurance coverage that made it feasible for clinicians to place patients based on their needs instead of financial abilities. Third, at high-performing hospitals a more engaged staff in the transition process and building rapport with SNFs characterized smooth transitions from hospitals to SNFs.

CONCLUSIONS AND IMPLICATIONS

Contextual factors distinguish high- and low-performing hospitals in transitions to SNF and can be used to develop interventions to reduce adverse outcomes in transitions.