Life In The Slower Lane

Here is the standardised PICO analysis for the forty-sixth uploaded article:

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Full Title

Implementing Transitional Care in Skilled Nursing Facilities: Evaluation of a Learning Collaborative

Authors: Mark Toles, Alesia Frerichs, Jennifer Leeman

Journal: Geriatric Nursing, 2021; 42: 863–868

DOI: 10.1016/j.gerinurse.2021.04.010

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Type of Study

Quality Improvement Evaluation using a prospective design and RE-AIM implementation framework

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PICO Summary

Population (P)

• Skilled Nursing Facility (SNF) patients in the USA, specifically:
  • Short-stay patients discharged to home (n=550)
  • Average age 78 years, 65% female, 84% White
• SNF staff involved in discharge planning (nurses, social workers, administrators) from 3 facilities across 3 states

Intervention (I)

Connect-Home transitional care intervention delivered through a learning collaborative, including:

• Four-step protocol:
  1. Goal setting for home care
  2. Care planning meeting
  3. Discharge preparation
  4. Post-discharge support
• Implementation strategies:
  • Collaborative training (off-site and on-site)
  • Quality monitoring and coaching
  • Record system modifications and audit tools
  • Staff-led small tests of change and EHR integration
• Adaptations during COVID-19: remote meetings, telephone-based education, outdoor or digital family engagement 

Comparison (C)

• No control group; evaluation focused on implementation outcomes rather than effectiveness outcomes

Outcomes (O)

(Using the RE-AIM Framework)

1. Reach

• 38 staff trained across 3 SNFs
• 550 patients received the intervention (100% of eligible short-stay discharges)
• 185 of these patients were admitted post-COVID onset

2. Adoption

• 3 of 4 invited SNFs adopted the intervention; 1 dropped out due to concurrent EHR implementation

3. Implementation

• High fidelity to intervention and implementation protocol:
  • Caregiver attendance at care planning: ~75%
  • Discharge summary completion: improved from 39% to 76%
  • Follow-up physician appointments scheduled: improved from 30% to 74%
  • Records faxed to follow-up physicians: improved from 67% to 93%
  • Follow-up calls within 72 hrs: improved from 47% to 64% 
• Positive qualitative feedback from staff on utility, communication, and care coordination

4. Maintenance

• All 3 SNFs planned to continue using revised discharge templates
• Champions identified sustainability goals, including integration into broader facility workflows
• COVID-19 presented ongoing challenges to sustainability

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Findings Summary

This real-world QI project demonstrates that a learning collaborative model can successfully implement a transitional care intervention in SNFs. Key enablers of success included:

• Use of internal and external implementation strategies
• Tailored training and tools
• Structured feedback and EHR integration

Staff reported improved confidence, clearer discharge processes, and better communication with home-based care providers. However, time burden, COVID-19 disruptions, and sustainability planning remained barriers. The study proposes that future pragmatic trials are needed to test this model’s generalisability and effectiveness on outcomes such as re-hospitalisation and caregiver burden.

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