Let nurses take the wheel

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Emily Mongan
Emily Mongan

On the ever-growing list of things long-term care providers need to be worried about these days (hello there, Phase 2 requirements), care transitions should be near the top.

After all, coordinating patients' moves from hospitals to skilled nursing facilities are what set great providers apart — and set them up for a strong financial future under programs like the bundled payment initiative. Experts have repeatedly stressed the importance of sharing data and a robust care transitions team in making a good impression on hospital partners.

But at the end of the day, who's really making sure a resident's move to a skilled nursing facility is the right one?

That was the question driving a study published Tuesday in the Journal of Gerontological Nursing. The Colorado University College of Nursing-based researchers knew a lot about care transitions from hospitals to nursing homes — namely that they're “often poorly coordinated” and put seniors at higher risk poor health outcomes.

But new payment initiatives like bundled payments are giving skilled nursing providers a chance to improve their care practices along with boosting payments. That kind of improvement requires an all-hands-on-deck approach, but little was known about the role nursing plays in these care transitions, the study's authors said.

To remedy that, they conducted nearly 100 interviews with clinicians, patients and caregivers from hospitals and skilled nursing facilities to determine who really has the reins when it comes to care transitions and determining the “fit” of a potential resident to a facility.

The study's results — which may not be surprising to those in the long-term care field — found that nursing home nurses are tasked with the primary role of managing that “fit” of a prospective patient to the skilled nursing facility they'll be moving into. Hospital nurses? Not so much, researchers said, noting the contrast between proactive nursing home employees and hospital nurses who “are often silent partners in post-acute care decision making.”

“Nurses are uniquely positioned to make needed changes to culture to adapt to new payment models and improve patient outcomes,” the investigators concluded.

So if there's a missing piece to the puzzle that is your care transition team, tap into this study's findings (and what experts have previously recommended) and elevate the voice of your nursing staff. Your future residents, and the money they'll help bring into your facility, may depend on it.

Follow Staff Writer Emily Mongan @emmongan.


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Daily Editors' Notes

McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Marty Stempniak.