Date on Paper
7-2024
Document Type
Doctoral Paper
Degree Name
D.N.P.
Department
Nursing
Committee Chair
Dr. Candace Harrington
Committee Member
Dr. Ratchneewan Ross
Author's Keywords
discharge planning; transitions in care; caregiver
Abstract
Background: A substantial body of evidence has shown transitions in care are one of the weakest links in healthcare networks, especially for older adults with complex comorbidities. Residents receiving short-term rehabilitation (i.e., rehab) transitioning to home from a skilled nursing facility (SNF) are the most vulnerable in the first 30 days post-discharge for adverse resident events, including avoidable rehospitalization. Avoidable rehospitalizations cost Medicare billions of dollars annually and lead to poor resident outcomes. Early discharge planning in SNFs for short-term stay rehabilitation has decreased rates of avoidable rehospitalizations, improved quality of life in geriatric residents, and improved care partners' perceived readiness.
Purpose: This quality improvement project aimed to improve the transition in care from rehab at a SNF to home by implementing an early discharge planning program that included regimented checklists and the involvement of residents, care partners, and the interdisciplinary care team.
Setting: A 66-bed skilled nursing facility in Louisville, KY, focusing on older adults receiving rehabilitation following hospitalization.
Methods: The discharge program consisted of a discharge planning checklist for social work and nursing staff with a supplemental discharge booklet. Data regarding compliance with the checklists, proof of documentation of early discharge planning, staff perception of the discharge program, and care partner perceived readiness was collected and analyzed.
Results: The discharge program showed improving compliance with early discharge planning and improved care partner confidence in taking on the home care of their loved one following discharge. We did not see a change in the documented need for community referrals upon admission in the Minimum Data Set (MDS). Care partners reported the Center for Medicare and Medicaid Services' discharge planning resource chosen for this project was not valuable.
Recommended Citation
Markgraf, Sarah, "Improving transitions in care through early discharge planning: a quality improvement Initiative." (2024). Doctor of Nursing Practice Papers. Paper 155.
Retrieved from https://ir.library.louisville.edu/dnp/155
