Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities

Abstract

Prior studies have not described strategies for implementing transitional care in skilled nursing facilities (SNFs). As part of the Connect-Home study, we pilot tested the Transition Plan of Care (TPOC) template, an implementation tool that SNF staff used to deliver transitional care. A retrospective chart review was used to describe the impact of the TPOC template on three implementation outcomes: reach to patients, staff adoption of the template, and staff fidelity to the intervention protocol for transition care planning. The template reached 100% of eligible patients (N = 68). Adoption was high, with documentation by four disciplines in 90.6% of patient records (N = 61). Fidelity to the intervention protocol was moderately high, with 73% of documentation that was concordant with the protocol. Our findings suggest an electronic medical record (EMR)-based implementation tool may increase the ability of staff to prepare older adults and their caregivers for self-care at home. Further research is needed to test the efficacy of the protocol on patient outcomes after transitions from SNF to home.

Keywords

transitional care care planning template skilled nursing facilities

Transitional care in skilled nursing facilities (SNFs) is a multicomponent intervention that supports patients who transfer from SNFs to home with the goal of preventing poor outcomes such as rehospitalization (Toles, Colón-Emeric, Asafu-Adjei, Moreton, & Hanson, 2016). As defined by the American Geriatrics Society, transitional care is a “set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location” (Coleman & Boult, 2003, p. 556). To date, implementing effective transitional care in SNFs is poorly understood.

A core element of transitional care is creating a patient-centered transition plan of care (Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011; Naylor et al., 2017) that serves as a “bridging intervention,” providing patient instructions for care at home and linking providers of facility-based and home-based services and supports (Hansen, Young, Hinami, Leung, & Williams, 2011). To develop a transition plan of care, clinical staff from many disciplines must identify patient needs and preferences and develop treatment goals and instructions for achieving them at home (American Medical Directors Association, 2010; Jack et al., 2009; National Transitions of Care Coalition, 2010; Snow et al., 2009). To date, most research on transition plans of care has focused on improving the transition from hospital to home or other settings. Research to improve the transition from SNF to home is needed to address the documented lack of input from family caregivers and the omission of key guidance about administering medications, monitoring changes in health, and participating in primary care follow-up (Lee, 2006; Toles et al., 2012; Toles, Colón-Emeric, Naylor, Barroso, & Anderson, 2016). Improving the quality of patient transitions from SNFs to home is significant because, in the United States, up to a third of SNF patients are discharged to home without an adequate transition plan of care (Department of Health and Human Services, 2013), and one in five patients require acute medical care within 30 days of transfers to home (Toles et al., 2014).

Implementation tools (e.g., clinical algorithms, electronic documentation templates, and pocket guides) are widely used to support nursing and other clinical staff as they integrate new care processes into routine practice (Gagliardi, Brouwers, Bhattacharyya, Guideline Implementation, & Application, 2014; Wandersman, Chien, & Katz, 2012). Although rarely used in SNFs, transitional care planning templates have been advocated for improving health transitions when patients transfer from hospitals to home, for example, to assure care planning of a core set of treatment domains for each patient, such as diagnosis, indicators that health status is worsening, special instructions for taking medication, and guidance for follow-up medical care (Agency for Health care Research and Quality, 2015; Society of Hospital Medicine, 2017). When embedded in hospital electronic medical record (EMR) systems, transitional care templates further increase the availability of information staff need to educate patients and caregivers, and create a written record of key instructions for use at home (Cipriano et al., 2013).

In an earlier publication, we reported on a study of the Connect-Home transitional care intervention in SNFs; the intervention provided tools, training, and technical assistance for existing SNF staff to develop and implement a transition plan of care in the SNF and in a postdischarge telephone call at home (Toles, Colón-Emeric, Naylor, Asafu-Adjei, & Hanson, 2017). Results demonstrated the feasibility and acceptability of the intervention, and its beneficial impact on patient and caregiver self-reported preparedness for discharge. As part of the study, we pilot tested the Transition Plan of Care (TPOC) template, a new implementation tool that SNF staff used to walk patients and caregivers through the Connect-Home intervention (Toles et al., 2017). Despite growing awareness of transitional care plans, prior studies have not evaluated the implementation tools used to integrate transitional care interventions into care settings. Thus, the aim of this article is to describe the impact of the TPOC template on three implementation outcomes: reach to eligible patients, staff adoption, and fidelity to the intervention protocol for transition care planning.

Method

A two-phase process was used to develop the TPOC and implementation strategies, and then, to pilot test them in three SNFs. Below, we describe development of the TPOC template, strategies used to implement the template in the SNFs, and the methods used in our pilot test of the impact of the template.

Development of the TPOC Template and Implementation Strategies

We designed the TPOC template to improve interdisciplinary communication and coordination within the SNF and to improve communication with those caring for the patient postdischarge. Staff in the SNF were responsible for completing the TPOC in the EMR system with the following goals: (a) focus transition planning in the SNF on evidence-based transitional care domains, (b) increase information flow and problem solving across disciplines, (c) provide a written record of information and goals for the patient and caregiver on the day of discharge (along with the reconciled medication list) to guide home-based care, and (d) create a record of transition plans for the patient’s follow-up medical clinicians.

An iterative process was used to write the prototype of the TPOC template, building on prior tests of transitional care in hospitals (Naylor et al., 2013; Verhaegh et al., 2014), the team’s case study research in SNFs (Toles, Colón-Emeric, Naylor, et al., 2016), and input from academic and practice-based experts in transitional care and SNFs. Next, SNF clinical and administrative staff reviewed the language and reading level, feasibility, and acceptability of the template prototype, which were subsequently revised. Finally, the TPOC template and Connect-Home intervention protocol were submitted to an advisory group, comprised of experts in patient care in SNFs, for final review and recommendations.

As illustrated in Table 1, the TPOC template is designed to organize transition care planning in 16 evidence-based domains. The rationale for this decision was to establish a standard set of 16 care planning domains, including five in nursing (such as medications), three in rehabilitation therapy (such as mobility), six in social work (such as discharge destination), and two in general domains (such as caregiver understanding of the plan). For each domain, the TPOC template is configured with a free-text field for staff documentation. The rationale for using free-text fields, as opposed to a “point and click” approach to documenting with drop-down menus, was to require individualized planning for each patient in each planning domain.

Table 1.

Transition Plan of Care Template: Domains, Topics, and Staff Assignment.

Domain	Topics for transition planning	Staff
Main problem	● Diagnosis or main problem from the index hospital stay	Nurse
Signs of worsening health	● Signs of acute health problems related to the diagnosis	Nurse
Emergency contact	● Name and telephone number of the person the patient/caregiver will call if help is needed?	Social worker
Medications	● Plan for obtaining medications at home ● Plan for using medications at home ○ New or changed medications ○ Administering medications at home ○ “As needed” medications ○ Using Coumadin ○ Using medications for pain or sleep	Nurse
New and continuing medical treatments	● Outpatient medical treatments ○ Dialysis ○ Rehabilitation therapy ● In-home medical treatments, such as ○ Wound care ○ Medications administered with a syringe ○ Diabetes care	Nurse
Disposition	● Where will the patient live when they leave the nursing home	Social worker
Mobility	● Expected mobility and transfer risks at home ● High-priority instructions or reminders to promote mobility and safe transfers ● Other instructions for preventing falls	Physical therapist
Self-care	● Expected self-care risks at home ● High-priority instructions or reminders to promote self-care ● Describe any other instructions for self-care	Occupational therapist
Speech and diet	● Speech or swallowing plans for care at home ● Diet at home	Speech therapist and Dietician
Advanced care planning	● Living will and health care power of attorney ● Medical Orders for Scope of Treatment (MOST) form ● Hospice or palliative care	Nurse
Caregiver understanding	● Primary caregiver name and contact information ● Caregiver role after discharge	Social worker and nurse
Home health	● Name and contact information of the home health agency	Social worker
Medical follow-up appointments	● Names of physicians/practitioners for follow-up care ● Dates, locations, and phone number for follow-up care	Social worker and other
Labs/studies	● Labs/studies needed after discharge to home? ● Dates, locations, and telephone numbers	Nurse
Community services	● Meals on wheels, pharmacy, transportation	Social worker
Miscellaneous	● Other special instructions, such as equipment ● SNF contacts and contact information	Any

Note. SNF = skilled nursing facility.

We conducted a feasibility test of the TPOC template with 10 patients. Initially, SNF staff reported that documentation requirements were too cumbersome. In response, we reduced the amount of required documentation for each domain and developed a “Cue Sheet” to identify topics for planning in each domain (Table 1, content from the TPOC Cue Sheet is summarized in column 2).

We used a multiple-step process to integrate the TPOC template within SNF routines of care. Before the intervention was implemented in the individual SNFs, the lead investigator and an information technology specialist in the SNF corporate office installed the Connect-Home TPOC template in the nursing home chain EMR system. Then, five additional implementation strategies were used to promote staff adoption of the TPOC template and fidelity to the Connect-Home protocol. First, an executive champion participated in meetings to establish implementation objectives and timelines. Second, a registered nurse in each SNF was trained as a site champion, including one director of nursing and two nurses in the dual role of minimum data set/case manager. Third, a total of five administrative and 46 clinical staff members (nurses, social workers, rehabilitation therapists, and administrative staff) completed 4 hr of in-person staff training to use the TPOC template and implement the Connect-Home protocol. Fourth, staff were given a printed copy of the “Connect-Home Implementation Toolkit,” a “Cue Sheet” for using the TPOC template, and paper copies of all study tools, agendas, and schedules. Finally, 46 staff members participated in audit and feedback cycles; the primary investigator used a standardized tool to audit patient records and provide written and verbal feedback with staff about adoption and fidelity to the Connect-Home protocol.

Pilot Testing the Impact of the TPOC Template

Design and sample for the Connect-Home pilot study

A retrospective medical records review was used to evaluate the TPOC template’s impact on implementation outcomes (Vassar & Holzmann, 2013). As described in a previous publication, the Connect-Home study was conducted with a nonrandomized, historically controlled design (Toles et al., 2017). Patients were eligible for inclusion if they (a) spoke English, (b) had no more than mild cognitive impairment or more than mild cognitive impairment and a legally authorized representative who represented them in the research, and (c) were discharged from the SNF to home (Toles et al., 2017). Of the 133 eligible patients, 68 were in the intervention arm and 65 in the control.

In this study of the TPOC template, medical records were reviewed for all intervention patients (N = 68), including 24 patients in SNF 1, 23 in SNF 2, and 21 in SNF 3. Seventy-nine percent of patients were female, mean age was 80 years, mean length of SNF stay was 26 days, and treatments in the SNF most commonly focused on nursing and rehabilitative care after orthopedic surgery (e.g., hip fracture) or medical conditions (e.g., pneumonia and congestive heart failure; Toles et al., 2017). All patients provided a written signed consent to participate in the parent study. Ethics approval to conduct the study was obtained at the University of North Carolina Institutional Review Board.

Implementation outcomes and data collection

Three implementation outcomes were assessed as indicators of the extent to which the Connect-Home care planning template was used as intended: reach to eligible patients, staff adoption of the TPOC template, and staff fidelity to the intervention protocol (Proctor et al., 2009; Proctor et al., 2011). Reach was defined as the proportion of patients in the intervention arm for whom the TPOC template was initiated. Adoption was defined as the proportion of patient records that included a TPOC template with documentation from four core members of the interdisciplinary team, including a nurse, physical therapist, occupational therapist, and social worker. Fidelity to the intervention protocol was defined as the extent to which use of the TPOC template was concordant with the transition planning guidance provided in the TPOC Cue Sheet (Table 1, column 2). Published instruments for evaluating the quality of transition care plans were not available; thus, we developed the TPOC Review Instrument to assess whether documentation in each TPOC template domain included the content specified in the Connect-Home protocol (fidelity to protocol). The TPOC Review Instrument included criteria for rating intervention fidelity in 11 of the 16 domains on a yes/no scale, with yes scored as 1 and no scored as 0 (see Supplementary File 1). Five domains were not relevant in planning of all patients (e.g., caregiver understanding was not relevant in care of patients with no identified family or other caregiver) and, therefore, were not included in the review; thus, accurate use of the template was defined as completing 11 domains, and the range of possible scores on the instrument was 0 to 11.

The lead investigator and a trained research assistant independently reviewed the TPOC for all patients in the intervention arm; agreement between evaluators was 100% for staff adoption of the TPOC tool and 94% for fidelity to the Connect-Home protocol. Differences in the way items were scored were resolved by consensus.

Analysis

The reach of the TPOC to eligible patients was calculated by dividing the number of times a template was initiated by the number of eligible patients (N = 68). Staff adoption of the template was calculated by dividing the number of TPOC templates with documentation from a nurse, physical therapist, occupational therapist, and social worker by the total sample of TPOC templates. Fidelity to the intervention protocol was calculated as the average number of domains per medical record that were concordant with the intervention protocol. In addition, we collected exemplar documentation of low versus high fidelity transition care planning from the TPOC across the sample. Data were managed and calculated in Microsoft Excel.

Results

Impact of the TPOC Template

Patient reach and staff adoption of the TPOC template

We found that SNF staff initiated the TPOC template in care of 100% of patients (n = 68). Documentation that all four disciplines adopted the TPOCs was found on 61 (91.6%) of those templates. In records of seven patients, reviewers could not determine the name or discipline of the individuals who completed one or more of the domains in the TPOC. Because information was incomplete, the TPOCs for these seven patients were excluded from the analysis of fidelity.

Fidelity of transition planning to the Connect-Home protocol

For the sample of 61 patients, the average number of TPOC template domains that included content specified in the Connect-Home protocol was 8.3 domains out of the 11 domains on the TPOC Review Instrument, indicating relatively high overall fidelity. The number of domains with content specified in the protocol covaried with setting: In SNF 1, the average was 7.2 domains; in SNF 2, the average was 8.5 domains; and in SNF 3, the average was 9.3 domains.

Exemplars of documentation that was and was not concordant with the intervention protocol are described in Table 2. There were five common patterns in documentation with low fidelity. First, in the “home health care” and “follow-up appointments” domains, documentation in 15% of records did not include critical details such as telephone numbers of caregivers and follow-up clinicians or service providers (Exemplar 1). Second, plans in the “signs of worsening health” domain identified a sign or a symptom to monitor but in 18% of records did not suggest an appropriate response, such as calling a physician for help (Exemplar 2). Third, plans in the “medical treatments” and “medications” domains indicated the name of a treatment or medication (such as use of a back brace) but in 25% of records did not describe procedures for continuing the treatment or medication at home (Exemplars 3 and 4). Fourth, in the “advanced care planning” domain, no records of patients with advanced care plans included complete information (Exemplar 5). Finally, plans in the “mobility” and “self-care” domains included technical jargon (15%) or did not describe specific instructions (e.g., falls prevention) for safety at home (18%; Exemplar 6).

Table 2.

Low vs. High Fidelity Documentation in the TPOC Template.

	Domain	Exemplar Quotes with low vs. high concordance with the protocol
(1)	Home health services	L	[Name] Home health agency will provide home care
(1)	Home health services	H	[Company name] has been selected as the home health agency. Please contact [Name, number]. It is anticipated that your evaluation with [Company name] will take place Wednesday. I have shared you are eager to start therapy and continue on the path of healing.
(2)	Warning sign of worsening health	L	If you have shortness of breath, coughing, temperature, if you cannot catch your breath
(2)	Warning sign of worsening health	H	Watch for increase in redness, warmth, or drainage to right knee incision. If so, call orthopedic surgeon, Dr. [name, number]. If you develop fever, cough, increased fatigue, this could mean a relapse of your pneumonia, call your primary care doctor [Name, number].
(3)	Medical treatments	L	I will continue to wear my special neck brace until my doctor tells me I can take it off.
(3)	Medical treatments	H	Wound care to back. Home health nurse for wound care and education with family. You are having wound cleansed with normal saline and packed with moist gauze twice a day. Remember to always wear your back brace when you are up. Make sure you have it tight enough. Readjust as needed. Also remember, “NO BLT” (bending lifting, twisting). Continue with no showers until cleared by surgeon.
(4)	Medications	L	I take my medications out of the bottles, not pill boxes. I know how to take them.
(4)	Medications	H	Continue with all the medications on your med list. You may experience loose stools while taking colchicine for the gout in your right foot. Continue to load your weekly pillbox on Saturday evenings. Call your orthopedist [Dr. Name] if Tylenol is not controlling your pain or if pain is increasing.
(5)	Advanced care planning	L	Upon my admission to the [SNF Name], you elected not to receive cardiopulmonary resusitation services in the event of cardiac arrest. You have a living will and have appointed your daughter [Name], as your power of attorney in the event that you are unable to make decisions with regard to your health, welfare, and affairs. Your son, [Name], will make decisions in the event that your daughter [Name] is unable.
(5)	Advanced care planning	H	No high fidelity exemplar
(6)	Mobility	L	Always follow precautions s/p sx until discharged by the physician. Shower bench use in tub shower for safety and energy conservation. Continue use of RW w/ADL and ADL transfer safety.
(6)	Mobility	H	Remember to monitor your Oxygen with the pulse oximeter for saturation (red tool) when you feel fatigued. If your oxygen level drops lower than 90%, please take a seat and rest. Remember to breathe deeply through your nose and out of your mouth to improve breath support. You can always use your walker to improve your endurance for longer distance walking.

Note. TPOC = Transition Plan of Care; L = low concordance; H = high concordance; SNF = skilled nursing facility.

Discussion

Progress has been made in developing effective transitional care interventions and improving health outcomes after older adults’ transfer between settings and providers of care. The next step is for this field to move from innovation to implementation to improve transitional care. Implementation tools have potential to standardize transitional care processes and integrate them into complex systems (Leeman et al., 2015; Toles et al., 2017; Wandersman et al., 2012). In this article, we report on development and implementation outcomes for the TPOC, an implementation tool developed to integrate the Connect-Home transitional care intervention into three SNFs. We found that the template was used for 100% of patients and that all involved disciplines adopted the template for at least 90.6% of patients. Findings also support staff fidelity to the tool (76%), with substantial interfacility variation in the extent that documented transition care plans were concordant with the protocol.

Taken together, these findings support the potential value of the TPOC as a tool for improving transitional care in SNFs. The TPOC template created a focal point for transition care planning in the SNFs and clearly articulated core domains of transitional care. The TPOC template replaced the “Discharge Summary” form in the SNFs, which did not include specific nursing, rehabilitation therapy, and advanced care planning goals or recommendations. By requiring written documentation, the TPOC overcame the limitations of the SNFs’ prior reliance on verbal communication of discharge goals and instructions among disciplines and to patients and sometimes caregivers. With the template, a complete set of transition plans were documented in one place, which created the opportunity for presenting a more unified overall plan to patients and their caregivers. The “Cue Sheet,” developed to support staff use of the TPOC template, provided detailed guidance on care processes and documentation required for each domain. This resource was critical for helping staff members learn and routinize elements of an evidence-based transition care plan.

Understood in terms defined in the “Applied Framework for Understanding Health Information Technology in Nursing Homes,” this study showed that, when integrated into the EMR system, the TPOC supported staff members’ successful implementation of the patient care protocol in the SNFs (Degenholtz, Resnick, Lin, & Handler, 2016). First, addressing the need to integrate patient care across fragmented settings and providers of medical care (Coleman, 2003; Ng, Harrington, & Kitchener, 2010), the TPOC enabled staff to more reliably document a complete description of the plan for home-based care. Although created primarily for the patient and caregiver, the SNF staff also faxed the TPOC to primary care clinicians (Toles et al., 2017). Second, preparing nursing homes to comply with pending readmission penalties (Carnahan, Unroe, & Torke, 2016), staff use of the TPOC template generated an auditable record of transition care planning for demonstrating compliance with regulatory standards. Third, using the TPOC template contributed data usable in quality improvement efforts; for example, in our assessment of staff fidelity, we found that no transition plan in the study included complete information about advanced care plans, which suggested an area for future quality improvement work. Fourth, staff use of the TPOC generated structured clinical information guided care in the SNF and during follow-up calls with patients after discharge (Toles et al., 2017). Finally, the TPOC template also supported patients and their caregivers with instructions for recommended medication use, and communicated clinical information for patients and caregivers to use at home (Toles et al., 2017). These findings suggest that implementation strategies, including an EMR template for transition care planning, promote the capacity of SNF staff to prepare older adults and their caregivers for self-care at home and prevent rehospitalization.

The TPOC template was designed with extensive staff input to ensure a pragmatic approach for staff to write brief, action-oriented, individualized goals and instructions for patients in 16 domains. The TPOC also may be used in future research to refine and tailor the Connect-Home intervention. Gaps in performance will require revisions to the training and technical assistance; in particular, additional staff training to (a) recognize and record advance care plans and (b) identify specific steps for responding to changes in health as they emerge. To address complex goals of care and implications for the care plan, additional patient educational materials are likely needed to supplement the TPOC, such as instructions for using warfarin, providing assistance with using shower benches and assistive devices, and more detailed instructions for health monitoring.

Future research is also needed to explain variations in performance across SNFs, information that may then be applied to tailor Connect-Home to fit the needs of different settings, for example, using fidelity monitoring in quality improvement cycles with staff across SNFs. Although initial pilot testing provided support for Connect-Home’s effectiveness (Toles et al., 2017), additional research is needed to confirm effectiveness and also to assess the role that TPOC adoption/fidelity plays in sustaining Connect-Home effectiveness on patient and caregiver outcomes.

The medical records review of the TPOC for intervention participants in the Connect-Home pilot study is limited by the small number of charts reviewed, the small number of SNFs that participated, and potential biases of the investigators who conducted the medical records review. Limitations in using a retrospective chart review to assess implementation outcomes limits the reliability of study findings; for example, if staff developed elements of a transition plan without consulting patients, the chart review potentially misidentified intervention fidelity. Moreover, in seven records it was not feasible with the chart review to determine which discipline recorded some of the patient’s goals in the TPOC, thereby limiting assessment of staff adoption using these records. Although the study has these limitations, it provides essential data about novel implementation strategies to deliver transitional care and improve patient and caregiver preparedness for discharge.

Conclusion

Gaps in the quality of transitional care place SNF patients at high risk of poor health outcomes. Recent changes in health care policy present an opportunity to invest in closing the quality gap. The U.S. Centers for Medicare and Medicaid Services will soon implement a value-based payment program designed to improve SNF patient and cost outcomes. Under this program, facilities with the lowest rate of hospital readmissions in 30 days will receive the largest payment, and facilities with the highest rate will receive payments less than they would have received before the program (Carnahan et al., 2016). The findings in this study suggest that an EMR-based implementation tool may strengthen the integration of transitional care best practices into SNFs’ care processes.

Supplemental Material

Supplementary_File – Supplemental material for Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities

Supplemental material, Supplementary_File for Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities by Mark Toles, Jennifer Leeman,Cathleen Colón-Emeric and Laura C. Hanson in Journal of Applied Gerontology

Footnotes

Acknowledgements

The authors wish to acknowledge Deb Tillman and Gail Hall who assisted with data collection.

Authors’ Contributions

Mark Toles designed the study and analysis plan, participated in the chart review and analysis, and drafted the article. Jennifer Leeman participated in the analysis, assisted with the literature review, and provided primary review of the article. Cathleen Colón-Emeric participated in the analysis and provided article edits. Laura Hanson assisted with the design of the study and the analysis plan, participated in the analysis, and provided article edits.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institutes of Health (1KL2TR001109). Mark Toles was also supported by the John A. Hartford Foundation.

Research Ethics and Patient Consent

All patients provided a written signed consent to participate in the parent study. Ethics approval to conduct the study was obtained at the institutional review board at the University of North Carolina Institutional Review Board, Number: 14-3,090.

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