Denver-Seattle Center of Innovation at Eastern Colorado VA Healthcare System, Denver, CO, USA.
Department of Community and Behavioral Health, Colorado School of Public Health, Aurora, CO, 80045, USA.
J Gen Intern Med. 2021 Aug;36(8):2251-2258. doi: 10.1007/s11606-020-06511-9. Epub 2021 Feb 2.
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.
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.
Semi-structured interviews with interdisciplinary hospital and SNF providers.
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).
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.
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.
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.
从医院到熟练护理机构（SNF）的过渡中，不良后果很常见。过渡护理流程中的差距导致了这些结果，但尚不清楚医院和 SNF 临床医生对于谁负责填补这些护理过渡中的差距有相同的看法。
我们旨在了解医院和 SNF 临床医生对过渡护理流程中角色和责任的看法，以确定可以解决以改善过渡的一致性和差距区域。
对跨 3 家医院和 3 家 SNF 的跨学科医院和 SNF 提供者进行半结构化访谈。
3 家医院和 3 家 SNF 的 41 名临床医生，包括护士（8 名）、社会工作者（7 名）、医生（8 名）、物理治疗师和职业治疗师（12 名）和其他工作人员（6 名）。
使用基于团队的演绎分析方法，我们将受访者的回答映射到理想过渡护理框架（ITCF）的 10 个领域，以确定医院和 SNF 之间的共识和差距区域。
尽管两组临床医生对理想过渡护理的概念相似，但他们的观点在 ITCF 的 10 个领域中有 8 个存在责任差距，包括出院计划；信息完整沟通；信息的可用性、及时性、清晰度和组织；用药安全；教育患者促进自我管理；争取社会和社区支持的帮助；协调团队成员之间的护理；以及出院后症状的管理。
随着医院和 SNF 越来越多地对在他们之间过渡的患者的结果承担共同责任，医院和 SNF 工作人员之间的角色和责任需要明确。改善过渡护理可能需要现场级别的努力、医院-SNF 联合倡议以及国家财政、监管和技术修复。同时，建立有效的医院-SNF 伙伴关系对于为弱势老年人群体提供高质量的护理变得越来越重要。
