People returning home from skilled nursing facilities need tailored instructions

Returning home after a stay in the hospital and a skilled nursing facility is often overwhelming. New research from Regenstrief Institute and Indiana University shows that individualized treatment plans and instructions would be beneficial to both patients and their caregivers.

“Patients who are discharged from the hospital to a nursing facility before being able to go home are an extremely vulnerable population,” said , who is the study’s first author, a research scientist at Regenstrief Institute and an assistant professor of medicine at Indiana University School of Medicine. “These patients often have more comorbidities and medically complex situations. The first few days at home are crucial to prevent adverse events, but we found that period is where the biggest gaps in care exist.”

Care transitions are burdensome for patients and are the points in time where errors and gaps in care are more likely. The transitions can affect quality of life and cause the patient to lose progress made during their stay at the care facility.

The research team interviewed two dozen patients and 15 caregivers about their experience returning home after spending time in the hospital and then a skilled nursing facility. The patients reported not having enough information about plans for the transition in care. They found informational paperwork they received overwhelming or not useful. Many had challenges managing medication, and some experienced a gap in physical and occupational therapy.

“I think I’ve missed the therapy … I’ve gotten kind of stiff and everything so I think if we could have started the therapy sooner it would have been better,” one patient told researchers.

“We need to develop a way to bridge this gap between nursing facilities and the home environments to set individuals up for a successful transition and a return to their normal lives,” said Dr. Carnahan. “Patients need very tailored and specific instructions, because they face many changes and adjustments.

“COVID-19 has exacerbated nearly all of these transitional challenges,” she continued. “It will be hard to meet face to face; occupational therapy may be difficult due to restrictions or risk of exposure to the virus. These are issues we need to consider moving forward in these transitions.”

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