The difficult transition between the hospital and nursing home

The difficult transition between the hospital and nursing home

Huge numbers of older persons transition from hospitals to the nursing home.  Often, an older hospitalized patient needs skilled nursing care before they are ready to return home.  In other cases, a nursing home patient who needed hospitalization is returning to the nursing home.  Older patients and their families certainly hope that great communication between the hospital and nursing home would assure a seamless transition in care.

But a rather stunning study in the Journal of the American Geriatrics Society suggests the quality of communication between the hospital and the nursing home is horrendous.  The study was led by researchers from the University of Wisconsin, including nurse researcher, Dr. Barbara King and Geriatrician Dr. Amy Kind.

The authors conducted interviews and focus groups with 27 front line nurses in skilled nursing facilities (SNFs).  These nurses noted that very difficult transitions were the norm.  Sadly, when asked to give the details of a good transition, none of the nurses were able to think of an example.

Most of the nurses felt that they were left clueless about what happened to the their patient in the hospital.  They lacked essential details about their patient’s clinical status.  The problem was not the lack of paper work that accompanied the patient.  In fact, nurses often received reams of paper work, often over 80 pages.  The problem is that the paper work was generally full of meaningless gibberish such as surgical flow sheets that told little about what was actually going on.

Often the transfer information had errors, conflicted with what the facility was told before the transfer, and lacked accurate information about medications.

Essentially, SNF nurses found themselves asked to care for patients with little sense of what actually happened in the hospital, and little insight into the functional and cognitive status of their patients.  These episodes of poor communication led to a number of adverse consequences:

  • Patients were put at risk for medication errors. In particular, patients were often left in pain while nurses tried to find a physician to write the orders for opioids that were not included with the transfer.
  • Efforts to mobilize patients were delayed while nurses tried to figure out what level of mobility was safe, as the transfer information did not indicate what level of ambulation was safe.
  • Time nurses should have been able to spend caring for patients was instead spent on trying to piece together the records and tracking down primary care providers and hospital providers to learn details about the hospitalization and the medicine regimen.
  • The nurses felt their credibility and the credibility of the nursing home were undermined with patients and families as the chaotic process made them look bad.  Patients and families assumed something was wrong with the nursing home.

King and Kind point to the need for serious efforts to improve the quality of transitions between the hospital and nursing home.  The type of communication problems noted in this article certainly must have a negative impact on patient outcomes.

Ken Covinsky is a professor of medicine, University of California, San Francisco who blogs at GeriPal.

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  • Steven Reznick

    I still have the ability to care for my patients in the office, attend in the hospital and follow them to the nursing home. I see what goes on firsthand. There is little or no communication between the inpatient physicians and the physicians caring for the patient at the SNF. Most of the non primary care physicians who care for the patient at the hospital have never been to an SNF and have little or no idea what level of oversight and care can be provided at these facilities. The nursing staffs at SNF’s are overwhelmed with ratios of patients to nurses being multiples of hospital patient to nurse ratios with the SNF patients being older, more complicated and generally on more medicines. The work at these facilities is physical, extremely hard and relies on lower paid aides with not much formal education. The staff turnover ratio at many of the facilities is > 75% per year because of the stressful nature of the work. Due to the economics of the situation and the excessive bureaucratic rules and regs these facilities must adhere to they are able to provide very little nursing and care. This is not because the staff members do not want to or do not care. It is just the opposite. It is a miracle that they get as much done as they do and a testament to their compassion and dedication to their patients.

    • kjindal

      I work at a large SNF in nyc, within the cachement of columbia-presbyterian, mt sinai, and other well-regarded tertiary centers. And it’s maybe 20% of admissions/readmissions to our facility that come with a clear discharge summary and ONE clear medication list. Often they will come with 2 different med lists, often conflicting, +/- a bunch of prescriptions which often don’t match either of the lists. Sometimes, e.g., we will get rxs for coumadin or other dangerous meds without a clear indication or diagnosis attached. Then trying to get info is often met with the “HIPAA police” blockade.

      This, of course, is only compounded by the electronic systems in place at both facilities that don’t talk to each other. And in our case, we have several systems WITHIN our facility that don’t talk to each other!

      I’ve said many times on this blog and elsewhere that, if the gov’t really wanted to save money by reducing care duplication and promote coordination, they easily could’ve picked a “winner” EMR system, given it to all entities that bill medicare (after all, the savings accrue to medicare, NOT to doctors & hospitals), then mandate that if you bill medicare, you must use that system.

    • Joel Walker

      Joel Walker

      Steve you bring up some very valid points, and I share them views, but I have some very explicit first hand views my self. I usually never like to be involved in negative overtones without having stated a possible solution to the problem.

      I’ve been on the receiving end of this topic of discussion. 15 years as a Paramedic on an Ambulance, worked in the Hospital Emergency rooms, Taught at the local college and from there I have aquired a great bit of knowledge , and learning about “Patient Transfer of care.”. The experiences I have had are some of the scariest to some of the best, they have varied in so many different ways. I can tell you from my overall experience that the communication gap lies in the hands of the inexperienced, poor grade nursing facilities and the administrative staff that runs the facilities along with poorly documented care that the hospitals rendered to the patient, and Steve is right that the physicians rarely ever communicate with each other when it comes to Emergency facilty care . It’s always the primary care physician that attempts communication with the nursing facility staff at the SNF, but the problem is with the continuity of care and true understanding of what happened between point A and point B while the patient was in dire care of emergency services and care was rendered. The knowledge is only then as good as it’s documentation that the Emergency facility has passed on, this is all they have to rely on ,unless they take the effort of making personal phone calls and tracking down the caring physician or clinitian e.g Nurse, PA, NP.

      Steve also brings up valid points about the nursing facility and it’s staff. A lot of these facilities are poorly managed ,under staffed and have poor standards, a lot of cases they are un-qualified and not much formal education , and Steve is also right in saying that probably most of the staff mean very well in providing best quality care they know how too, but the work load and mis management at some of these facilities is herendous.

      I would like to state a solution or possible fix to some of these problems , which is not a very easy task . These facilities (SNF) are all out to make a profit like most businesses and they do suffer through a lot of bureaucratic red tape and rules are constantly changing for these facilties. With the economy and the rules that are changing it has had a major impact on the way these SNF are run today and making it even harder for these facilties to stay alive. The Goverment has made drastic cuts on medicare/Medicaid which has disqualified some of the kick backs they were getting before , and now the nursing homes , Hospitals and EMS businesses have had to make major changes in the way they do business. You see today a lot of these hospitals , nursing facilties , EMS systems are all in a restructuring mode and attempting to find new and inventive ways on how to survive in the world of health care . S for the SNF the only real suggestion I can give is for these facilties to focus on good patient care and better oversite , whilst having good management. Being creative and offering new inventive ways to care for the patients/residence so to enjoy the rest of their years or what they have remaining.

  • guest

    Interesting that all of these pts are medicare. Medicare is so busy billing for procedures there is just no time for taking care of elderly pts it was made to cover. Where did I read recently, the best way to judge the morality of a country is how they treat their most vulnerable?( Elderly, sick etc.)

  • Suzi Q 38

    It is so hard to find a good nursing home.
    The meds are a big problem.
    Once the nurses forgot to give my FIL meds for 5 days.
    He was a tough guy, he still didn’t die.

    He fell out of bed a couple of times. They always called me to let us know. Since he had lived with us for 7 years prior, we understood how difficult it was to keep track of him 24/7.

    They are so short staffed that a lot can happen.

    • SarahJ89

      It’s not doughnuts. You just learn over time which nursing homes are the good ones. It’s pretty obvious when you have patients bouncing back into the hospital for things like falling out of bed. I remember one nursing home staffer was killed by being run over by a lunch tray cart.

      The worst place in the area of the hospital in which I worked was the one right next door to the hospital. It was owned by the doctors so we were pushed to place people there.

      It was always a coup to get a patient into a good home, especially a Medicaid patient–you know, those people who paid taxes all their lives.

      You’re right on target about working with a good hospital social worker.

    • SarahJ89

      And yes, as a former nursing home staffer–patients with people in their lives taking an active part in monitoring their care got MUCH better care. The staff was on notice in those cases.

      Which, as a childless woman with little or no family, gives me pause as I age.

  • 1themecca

    We had the good fortune to get my mom admitted to one of the best nursing homes in the area. She was on long term coumadin therapy due to a mitral valve replacement several years earlier. At an advanced age, suffering from dementia, but still living at home in the care of my father, she fell, and hit her head, resulting in a subdural which we opted to have drained, with good results, and was admitted to said SNF. Two or three days later we noted increased swelling of her ankles. In questioning the nurses at the SNF, it was discovered that NONE of her meds had been restarted at the facility….no lasix, coumadin, keppra, etc etc. I found it hard to believe that any nurse could look at her history and not realize that SOMETHING was missing. Where were her meds? Sounds like common sense to me, and this is at one of the best places for care. I was wrong in letting my guard down. Yes, everyone needs that advocate.

  • medicontheedge

    Whew… As someone who has worked in the medical field for almost 30 years, and had frequent and daily interactions with SNF’s, ED’s, patients and nurses, etc, I can tell you from MY experience, that the breakdowns in patient care, continuity, and communication are overwhelmingly the fault and responsibility of nursing home staff. Just ask any ED nurse about the interactions, or lack thereof, with “nurses” at convalescent homes. Residents are sent in often lacking relevant information, and on the other end, detailed info is not only sent back in written form, but a telephone report is also given… and stuff STILL falls thru the cracks.
    Advice given here about an active involved family is spot on. If a resident lacks advocates that are frequent visitors, they are literally ignored to death.

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