The Residential Long-Term Care Role in Health Care Transitions

The objective of the current study is to describe the activities long-term care facilities are undertaking to reduce hospital admissions and readmissions by working to improve health care transitions. The data were collected via an online survey from 888 nursing facilities (NFs) and 527 residential care facilities (RCFs) that completed the care integration module of the Ohio Biennial Survey of Long-Term Care. Questions focused on partnerships, current work, type of care model, and perceived barriers to reducing hospital readmissions. More than nine in 10 (93.1%) of NFs and 63.6% of RCFs reported being engaged in a program to reduce hospital admissions/readmissions. Evidence-based care models were utilized by two thirds of NFs and one third of RCFs. Financial barriers were the most frequently cited challenges faced by facilities. Long-term care settings are increasingly becoming transitional care stops for short-term stay residents. Ensuring that facilities are well versed in current transition research and practice is critical to improve system outcomes.