Running head: IMPORTANCE OF COMMUNICATION IN TRANSITIONAL CARE 1

The Importance of Communication in Transitional Care

Christine E. Davis

Delaware Technical Community College

NUR 340 Nursing Research

February 22, 2019

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Transitional care is when a patient transfers from a health setting to another health setting

or back to home. Readmission rates are high and is it due to gaps within the transition and

improper information given to the patient and caregivers during their transition. Communication

during the transition is critical for all involved. On October 1, 2011 the Centers for Medicare &

Medicaid Services (CMS) has started to fine hospitals for readmissions called the Health

Readmissions Reduction Program (HRRP). One in five Medicare enrollees is readmitted to the

hospital within 30 days, and up to 75% of these readmissions are preventable The purpose of this

paper is to see how communication is effecting the patient, before, during and after the transition.

The patients that participated were, stroke victims and their caregivers, skilled nursing facilities,

and hospitalized older adults.

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Statement of the problem

I am an Rn at a rehabilitation/Long term care facility, I have only been there for a year

and I have seen so many readmissions, usually within 30 days from their last stay. It has been

very frustrating for me, I feel that we did all we could to get them back to a baseline in order for

them to care for themselves at home. My question is “Why are there so many readmissions,

where is the WEAKNESS, what more or what differently could I have done as their nurse?”

Hospitals are being fined for a 30 day readmission, and it is costing the United States healthcare

billions of dollars. This review is important because nurses are a major part of the care

continuum, we are at the bedside more often, and are able to communicate with health team

members to make changes during their care continuum. Gaps in hand off can have dire

consequences. Nurses are the ones giving and receiving report when going on the floor or

accepting a new admission. Nurses are the ones that are giving patients their discharge orders,

and reading the orders from the doctor to them. Communication is a heavy load on our shoulders,

and research is showing that the better the communication the better for the patient not to be

readmitted.

Literature review

There are multiple medical diagnosis that require a patients’ need for transitional care,

due to their baseline changing. In this review I am comparing transitional care in a skilled

nursing facility (SNF), stroke victims and their care givers and hospitalized older adults. These

areas are of importance because once transitioned the patient will be needing a different level of

care. Nurses play the most important role in the transition communication process, they

strategically develop and communicate the transitional care plan by knowing what information
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should be communicated, and by extending a dialogue to the receiving team and understanding

what information they feel is necessary to provide the best follow-up care possible (Barbara,

2017).

Skilled Nursing Facility

Patients at times need additional care following a hospitalization, SNF’s provide a

short/long-term stay receiving 24 hours of care before the patient is transitioned to home. The

data provided shows that a SNF patient experience a greater risk for a poorer outcome as they

transition to home. According to Nelson and Pulley (2015) poor coordination between the acute

setting and primary care provider results in poor longitudinal care planning. The readmission rate

for patients discharged to skilled nursing homes is 25% within 30 days costing health care

billions of dollars (Nelson & Pulley, 2015). The qualitative data from a multiple case study done

in 3 SNF’s for 10 weeks by Toles, Colon-Emeric, Barroso and Anderson (2016), shows that high

quality organizational structures and care-team interactions will allow staff to deliver transitional

care services, which are the specific services to promote continuity and coordination of care as

older adults transition between settings and providers of care. This multiple case study provides

information on how improving care team communication with the patient and caregiver before,

during, and after the transition has proven to lower readmissions. This multiple case study also

provides information on how nurses can provide information to the patient and caregiver.

Hospitalized Older Adult

A 10 week multiple case study done by Hirschman et al. (2015) shows that there are six

overlapping categories of problems. This study states that there were gaps that were involved

during the patients’ transition. This evidence based article shows that using Mary Naylor’s
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Transitional Care Model and its 9 components has consistently demonstrated effectiveness in

addressing the needs of older adults while reducing re-hospitalizations and healthcare costs. This

model has been at the forefront of evidence-based care across health settings and providers.

Bronstein et al. (2015) did a quantitative analysis that shows that using a Masters in

Social Work (MSW) Intern, before, during and after a patient in transitional care, the intervention

improved the likelihood of not being readmitted by some 22 percent and having a MSW intern

intervention was highly significant. This study shows the significance of how important

communication and involvement are during transitional care.

In a qualitative analysis, the randomized controlled trial patients who received the RED

experienced a 30 percent lower rate of hospital utilization within 30 days of discharge compared

to patients receiving usual care (Jack et al, 2016). This trial consisted of a set of activities and

materials for improving the discharge process.

Stroke Victims and their Caregivers

Stroke is devastating to everyone involved. It can cause a large decline in the patients’

baseline, or barely effect anything. A stroke happens suddenly, and there is no time for the patient

or their caregivers to be prepared. According to Lutz et al. (2015) the critical first steps in the

Improving Stroke Caregiver Readiness Model process are to conduct a comprehensive

assessment of the patient’s needs and the caregiver’s readiness to assume the caregiving role.

This will allow us to identify gaps and prioritize interventions that are appropriately tailored to

the needs of the family to ensure appropriate family-centered care, after transitioning. Nurses are

the linchpin in the coordination of patient care, and thus are best equipped to coordinate a

successful transition (Barbara, 2017).

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Analysis

The research for transitional care has a long way to go. The articles that I have analyzed

are proven to be a good start. The information, pertaining to my question, each one contains the

importance of communication between the health care providers and the patient. Nurses are at

the forefront of communication. Having a nurse involved conducts a comprehensive assessment

of the patient’s health status, health behaviors, level of social support, and goals; develops an

individualized plan of care consistent with evidence-based guidelines, in collaboration with the

patient and her doctors; and conducts daily patient visits, focused on optimizing patient health at

discharge.

The gaps in these articles on transitional care are the differences in the patients’ health

status, the patients’ co-morbidities, the help the patient is receiving when transitioned, and the

different types of models to use during a transition. The SNF research felt that with the staff

knowing that the study was focused on transitional care it may have influenced the staffs’

behavior and applied bias to the study.

The methodologies used in these articles were grounded analysis by using open ended

questions, qualitative research by observations of care and care-team interactions, and thematic

analysis was used to describe similarities and differences in transitional care that was provided.

Evidence based practice was the result of many transitional care models that are now being used.

There are several transitional care models that have been analyzed and researched, the data is

showing that using one of the models can reduce readmissions by 45%. Transitional care is a

deep subject and there are so many models to review. They are finding that some models work

great in some areas and not in others.

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Recommendations

The most appropriate research that would answer my research question would be qualitative

research. Qualitative research allows us to compare and contrast what is working and not

working with transitional care. Using qualitative research would also allow us to make changes

during the process. Personal interviews would allow us to see the dynamics of their life outside

of the hospital, in turn allowing us to better prepare a care plan for their transition to home.

If I were to do a study on transitional care, I would begin with working with patients

that have gone through a transition; first without a readmission, then with a 30 day readmission.

The importance of what was communicated to the patient throughout the transition will help

determine what needed to be changed or not to be changed. Transitional care has three stages the

before, during and after, I feel the before is the most important. My title for this study would be,

“Finding & Fixing Failure with a Patients’ Transition”. The methodology I would use would be

grounded analysis, no one knows what works best until it is spoken from the person that has

experienced it. The grounded analysis has a “let it speak for itself,” which in turn would help

separating all the different transitional care models that do and don’t work. Asking direct open

ended questions to the patient and care giver will build a foundation on what information is

important, what information is missed, and most importantly what information has to be given at

the beginning of transitional care for the patient to avoid a readmission.

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References

Barbara, D. (May 24, 2017). The important role nurses play in care transition and reducing

readmissions. The Connected Clinician. Retrieved from

http://www.theconnectedclinician.com/the-important-role-nurses-play-in-care-transition-

and-reducing-readmissions/

Bronstein, L., Gould, P., Berkowitz, S., James, G. & Marks, K., (July 1, 2015). Impact of a

Social Work Care Coordination Intervention on Hospital Readmission: A Randomized

Controlled Trial, Social Work, Volume 60(3). 248–255. Retrieved from

https://doi.org/10.1093/sw/swv016

Hirschman, K., Shaid, E., McCauley, K., Pauly, M., Naylor, M. (September, 2015). Continuity of

care: The transitional care model. OJIN: The Online Journal of Issues in Nursing, 20(3).

Retrieved from https://doi: 10.3912/OJIN.Vol20No03Man0

Jack, B., Paasche-Orlow, M., Mitchell, S., Forsythe, S., Martin, J. (April, 2016). How Hospitals

Reengineer Their Discharge Processes to Reduce Readmissions. Agency for Healthcare

Research and Quality 38(2):116-26. Retrieved from

https://www.ahrq.gov/professionals/systems/hospital/red/toolkit/index.html

Lutz, B., Young, M., Creasey, M., Martz, C., Eisenbrandt, L., Brunny, J., Cook. C. (2017).

Improving stroke caregiver readiness for transition from inpatient rehabilitation to home.

Gerontologist. 57(5), 880–889. Retrieved from https://doi-

org.libproxy.dtcc.edu/10.1093/geront/gnw135

Nelson, J, & Pulley, A. (April, 2015). Transitional care can reduce hospital readmissions, a

bundle of activities linked to transitional care principles can reduce both short- and long-
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term readmission risk. American Nurse Today. 10(4). Retrieved from

https://www.americannursetoday.com/transitional-care-can-reduce-hospital-readmissions/

Toles, M., Colón-Emeric, C., Naylor, M. D., Barroso, J., & Anderson, R. A. (2016). Transitional

care in skilled nursing facilities: a multiple case study. BMC Health Services Research,

16, 186.Retrieved from https://doi:10.1186/s12913-016-1427-1