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Objective: Identify older adults who are at high risk for readmission following a skilled nursing facility stay that would benefit from a nurse practitioner visit within 72 hours of skilled nursing facility discharge. This improvement project aims to decrease 30-day hospital readmission rates following a skilled nursing facility stay by 20% through implementation of transitional care services. Additionally, information obtained during implementation will be provided to stakeholders in the skilled nursing facility as well as home-based primary care to inform of any gaps in care identified.
Methods: This improvement project will be completed at one facility in North Carolina and will include older adults considered at high risk for readmission following a skilled nursing facility. Risk will be determined through use of the LACE index and electronic frailty index (or Rockwood Clinical Frailty Scale if needed). Patients who meet criteria will be seen for a transitional visit in their home within 72 hours by a nurse practitioner. This visit will focus on medication reconciliation, physical exam findings, assurance that appropriate follow-up is in place, disease self-management education, environmental hazard assessment, confirmation that therapy services have been initiated, and DME received.
Results: Project is currently being implemented. Anticipate a reduction in 30-day readmission following a skilled nursing facility stay in high-risk older adults.
Clinical relationship: It is estimated that approximately 22% of older adults are seen in the emergency department or require hospital admission within 30 days following a skilled nursing facility discharge. Literature is limited in regards to transitional care following a skilled nursing facility stay. Literature that is available support the benefits of utilizing nurse practitioners for care transitions which has been shown to cut costs, decrease readmissions, and improve outcomes.
Impact or significance: This improvement project will provide support for the use of nurse practitioners for transitional care following a skilled nursing facility stay. The findings from this improvement project can be generalized to any high-risk older adult transitioning from a skilled nursing facility to home.