Health Optimization Program for Elders: Improving the Transition From Hospital to Skilled Nursing Facility

Area of Science:

• Geriatrics
• Health Services Research
• Patient Care

Background:

• High rates of unplanned hospital readmissions occur for patients discharged to skilled nursing facilities (SNFs).
• Transitional care for these patients presents an opportunity for significant improvement.
• Lack of real-time communication between hospital and SNF physicians hinders effective care coordination.

Purpose of the Study:

• To develop and evaluate the Health Optimization Program for Elders (HOPE) to enhance patient transitions from hospitals to SNFs.
• To determine if an NP-led transitional care program can reduce hospital readmissions.

Main Methods:

• A multidisciplinary team implemented the HOPE program.
• The HOPE program utilized a nurse practitioner (NP) to manage patient transitions.
• The NP identified geriatric syndromes, managed expectations, assessed rehabilitation potential, clarified goals of care, and facilitated communication with SNF providers.

Main Results:

• The HOPE intervention was feasible and addressed unmet needs in the SNF transition process.
• The program successfully mitigated errors occurring during patient transfers.
• Patients enrolled in HOPE experienced lower 30-day readmission rates compared to a control group.

Conclusions:

• An NP-led transitional care program from hospital to SNF shows promise for improving patient outcomes.
• This model of care effectively enhances the hospital to SNF transition process.
• The HOPE program demonstrates a viable strategy for reducing readmissions.