The Residential Long-Term Care Role in Health Care Transitions

Abstract

The objective of the current study is to describe the activities long-term care facilities are undertaking to reduce hospital admissions and readmissions by working to improve health care transitions. The data were collected via an online survey from 888 nursing facilities (NFs) and 527 residential care facilities (RCFs) that completed the care integration module of the Ohio Biennial Survey of Long-Term Care. Questions focused on partnerships, current work, type of care model, and perceived barriers to reducing hospital readmissions. More than nine in 10 (93.1%) of NFs and 63.6% of RCFs reported being engaged in a program to reduce hospital admissions/readmissions. Evidence-based care models were utilized by two thirds of NFs and one third of RCFs. Financial barriers were the most frequently cited challenges faced by facilities. Long-term care settings are increasingly becoming transitional care stops for short-term stay residents. Ensuring that facilities are well versed in current transition research and practice is critical to improve system outcomes.

Revisiting the Role of Physicians in Assisted Living and Residential Care Settings

“…Residents may transfer to a dementia care unit co-located on the same property, offsite, a SNF, or another care setting (Shippee, 2009). Other transitions during residents' tenure in AL/RC may include hospitalizations or treatment in acute care rehabilitation centers (Berish et al, 2018). A qualitative study of AL/RC and SNF residents and their families found that few received information about reasons for hospital admissions, had limited contact with physicians during hospitalization, and expressed uncertainty about treatments and discharge planning (Toles et al, 2012).…”

What Predicts Health Care Transitions for Older Adults Following Introduction of LTSS?

“…First, our findings suggest that LTSS recipients commonly experience health care transitions to and from both acute and non-acute settings of care. Although much of the health care transitions literature for LTSS recipients has focused on acute hospitalizations (Becker, Boaz, Andel, & DeMuth, 2012; Berish, Applebaum, & Straker, 2016; Cai & Temkin-Greener, 2015; McAndrew, Grabowski, Dangi, & Young, 2016; Sonnega, Robinson, & Levy, 2017), our study also examined non-acute care transitions (e.g., transitions to SNF/IRF settings, to hospice, between LTSS settings), which is a unique contribution to the literature. These non-acute care transitions accounted for 17% of the transitions occurring during the first 24 months of care for LTSS recipients.…”

Transitions From Acute Care to Long-Term Care: Evaluation of the Continued Access Model

“…The literature shows that among Medicare beneficiaries, almost 25% of those discharged to a skilled nursing facility are readmitted to the hospital within 30 days (Mor, Intrator, Feng, & Grabowski, 2010). At the same time, LTPAC settings themselves are becoming more transitional to accommodate a growing number of short-term rehabilitation patients (Berish et al, 2018). The “Continued Access” model considered in this article demonstrated the capability of providing LTPAC clinicians with direct access to the patient hospital chart to provide thorough patient health information in a more timely way than a traditional summary of care faxed to the LTPAC.…”

“…To address this, many LTPAC facilities are involved in preventing hospital readmissions. According to research by Berish, Applebaum, and Straker (2018), the majority of nursing facilities (over 93%) and residential care facilities (over 63%) in their Ohio survey reported being part of a hospital readmission program. The quality of transitions of care is critical in keeping hospital readmission rates low, necessitating effective methods to improve communication between the discharging hospital and the LTPAC facility upon admission of the new patient.…”