CONNECT appears to enhance the use of social constructivist learning processes among nursing home staff. The impact of CONNECT on clinical outcomes requires further study.

After hospitalization, 1.5 million older adults each year receive post-acute care in skilled nursing facilities (SNF). Transitional care services, designed to prepare older SNF patients (and their family caregivers) for their transitions from a 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 on 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.