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Related Concept Videos

Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

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Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
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Restorative Care01:19

Restorative Care

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Restorative care is provided once a patient has been discharged from a healthcare facility and requires additional services. The additional services include home care, rehabilitation programs, and extended care. Restorative care centers help the patient regain their previous level of functioning or acquire a new level of functioning due to the incapacitating effects of a disease or a disability. It aims to assist patients in enhancing their quality of life by encouraging independence,...
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Specialized Care Centers and Settings-II01:30

Specialized Care Centers and Settings-II

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Rural Health Centers
Rural health centers are specialized care facilities in remote locations with very few medical personnel. The primary care providers who run the centers are mostly Registered Nurse Practitioners. Here, emergency treatment is provided to critically ill or injured patients before they are transferred to the closest hospital. Fortunately, due to advancement in technology, many rural healthcare facilities and professionals have easy access to diagnostic and treatment...
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Continuing Care01:25

Continuing Care

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Continuing care describes the variety of health, personal, and social services provided over a prolonged period. The need for continuing care is increasing because people are living longer. Many people do not have families or others to care for them. Continuing care is mainly for patients who are disabled, functionally dependent, or suffering from a terminal disease. It is available within institutional settings or in homes. Examples include nursing centers or facilities, assisted living,...
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Specialized Care Centers and Settings-I01:30

Specialized Care Centers and Settings-I

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Specialized care settings or centers are situated in convenient locations within the community and offer care to a specific group or population. They consist of daycare facilities, mental health facilities, rural health facilities, educational institutions, industries, shelters for the homeless, and rehabilitation facilities.
Daycare centers
They provide several functions. Some facilities care for healthy newborns and children whose parents work, while others are medically focused and care for...
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Methods of Documentation VI: Case Management Model01:15

Methods of Documentation VI: Case Management Model

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The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
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Related Experiment Video

Updated: Mar 21, 2026

Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit
06:52

Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit

Published on: September 30, 2020

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Transitional care in skilled nursing facilities: a multiple case study.

Mark Toles1, Cathleen Colón-Emeric2, Mary D Naylor3

  • 1University of North Carolina at Chapel Hill, School of Nursing, 7460 Carrington Hall, Chapel Hill, NC, 27599, USA. mtoles@email.unc.edu.

BMC Health Services Research
|May 18, 2016
PubMed
Summary
This summary is machine-generated.

Transitional care services in skilled nursing facilities (SNFs) are crucial for older adults. This study found that effective transitional care relies on strong organizational support and team interactions within SNFs.

Keywords:
Older adultsSkilled nursing facilitiesTransitional care

Related Experiment Videos

Last Updated: Mar 21, 2026

Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit
06:52

Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit

Published on: September 30, 2020

10.9K

Area of Science:

  • Gerontology
  • Healthcare Management
  • Nursing Research

Background:

  • Hospitalized older adults transitioning from skilled nursing facilities (SNFs) to home face a 22% risk of requiring further acute care within 30 days.
  • Transitional care services improve care continuity but haven't been studied in SNFs.
  • This study aimed to describe transitional care delivery by existing SNF staff to identify improvement areas.

Purpose of the Study:

  • To describe how existing staff in skilled nursing facilities (SNFs) deliver transitional care services.
  • To identify organizational structures and care-team interactions that support transitional care delivery in SNFs.
  • To uncover opportunities for enhancing transitional care for older adults transitioning from SNFs to home.

Main Methods:

  • A prospective, multiple case study design involving three purposefully selected SNFs.
  • Data collection included 235 observations, 66 interviews with staff, patients, and family caregivers, and 35 document reviews.
  • Thematic analysis was employed to examine transitional care practices, organizational support, and care-team dynamics.

Main Results:

  • One SNF (Case 1) demonstrated comprehensive transitional care services, unlike the other two (Cases 2 and 3) with incomplete or absent services.
  • Staff in Case 1 exhibited a clear understanding of transitional care needs, utilized formal team meetings and tracking tools, and engaged in strong team interactions.
  • Differences in service delivery correlated with organizational structures and the quality of staff interactions.

Conclusions:

  • Organizational structures and robust staff interactions within SNFs are key to delivering effective transitional care.
  • Findings suggest developing new routines, tools, and training for existing SNF staff to improve transitional care.
  • Enhancing SNF-based transitional care can potentially reduce readmissions and improve outcomes for older adults.