February 2022

Heading Home

Trom a Skilled Nursing Facility:
Interventions and Tools

for Improving the Transition

Joan Guzik, MBA

Director, Quality and Efficiency, Quality Institute, United Hospital Fund

Pooja Kothari, RN, MPH
Consultant, X4 Health

Transitions of care, when a patient moves from one care setting to another, are

a vulnerable time. Inadequate preparation for transitions frequently places frail
and otherwise vulnerable older adults at risk of overuse of acute care services,
declining health, permanent residency in a skilled nursing facility (SNF), and high
levels of stress, anxiety, and dissatisfaction.

To address the historically limited focus on transitions of care from a short-

term stay in a SNF to home, United Hospital Fund launched a two-year learning
collaborative with eight SNFs in the New York City metropolitan region with the
support of the Mother Cabrini Health Foundation. This project's primary purpose
was to improve the quality of transitions for patients from skilled nursing facilities
to home by engaging SNFs and the patients and family caregivers they serve.

This report and toolkit provides a description of our learning collaborative
approach, profiles several interventions undertaken by the participating
facilities, and provides resources that can be useful to SNFs and other health
care organizations as they focus on ensuring successful transitions to home for
patients and their caregivers.

 

O6 Hostal Fund

Improving Health Care
for Every New Yorker
 

Introduction

Transitions of care, when a patient moves
from one care setting to another, are

a vulnerable time for elderly patients,
particularly for frail elderly patients with
multiple chronic conditions. While the health
care community has focused on patients
moving from an acute care hospitalization
back home or to a skilled nursing facility
(SNF), there has been less emphasis on

the needs of patients and family caregivers
returning home following a short-term stay in
a SNF for rehab or subacute care. Nationally,
fewer than 53% of short-stay patients at
SNFs had a successful discharge home or

to community-based services (defined as no
hospitalizations or deaths within 31 days).!

Inadequate preparation for transitions
frequently places frail and otherwise
vulnerable older adults at risk of overuse

of acute care services, declining health,
permanent SNF residency, and high levels

of stress, anxiety, and dissatisfaction. For
Medicare beneficiaries with multiple chronic
conditions, lower socioeconomic status,

dual Medicare/Medicaid eligibility, cognitive
impairment, or limited English proficiency, the
risk of poor outcomes is even higher. As the
population ages and the prevalence of chronic
disease rises, safe, effective, and person-
centered transitional care plans will become
even more essential. To ensure that transitions
succeed, SNFs will need to play a central role
in developing and facilitating them so that

patients and families are better equipped to
manage their care.

UHF has a long-standing interest in and
commitment to improving transitions of care.
To address the historically limited focus on
transitions of care from a short-term stay in
a SNF to home, UHF launched a two-year
learning collaborative with eight SNFs in the
New York City metropolitan region with

the support of the Mother Cabrini Health
Foundation. This project's primary purpose
was to improve the quality of transitions

for patients from skilled nursing facilities

to home by engaging SNFs and the patients
and family caregivers they serve. A list of the
facilities that participated in the initiative is
provided in Appendix A. Participants in the
collaborative sessions from the SNFs typically
included leaders from social work, nursing,
and administration.

This toolkit provides a description of our
learning collaborative approach, profiles
several interventions undertaken by the
participating facilities, and provides resources
that can be useful to SNFs and other health
care organizations as they focus on ensuring
successful transitions to home for patients and
their caregivers. Also included are potential
areas for future work that require attention
from providers, policymakers, and other
stakeholders.

1 CMS Nursing Home Compare - average based on data collection period 10/1/17-9/30/19.

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT
Project Description

The collaborative was launched during the
COVID-19 pandemic, which raised several
challenges particular to this project: in addi-
tion to suddenly caring for many patients with
COVID, SNFs were navigating staff shortages,
lack of personal protective equipment, and
fast-changing regulatory requirements-as
well as restricted family visitation, which
made transition planning and care confer-
ences harder to arrange. The first year of the
learning collaborative focused on engaging the
SNFs and providing information on common
challenges in transitions of care and discussing
evidence-based practices and interventions
that have been developed to address these
challenges. Topics covered in the learning
sessions during the two-year collaborative
included quality improvement tools (e.g.,
process mapping, fishbone diagrams), medi-
cation management in the elderly, identifying
and addressing social needs, transition of care
tools, use of "teach-back"? for patient educa-
tion, and implementing the age-friendly health
systems framework in nursing homes. A
complete list of learning sessions held during
the collaborative can be found in Appendix

B. Early in the collaborative, with the support
of the UHF team and the program faculty, the
SNFs mapped their discharge planning pro-
cesses and identified a lack of standardization,
gaps in team communication, limited patient
and family engagement, and inadequate
patient and family education about their con-
ditions and care needs upon return to home.
Engaging the interdisciplinary SNF teams in
mapping their discharge planning process was
a critical step in laying the groundwork for
the interventions that followed.

In addition, UHF engaged a market
research firm to conduct a survey of recently

discharged patients and family caregivers from
the eight SNFs in the collaborative to evalu-
ate their experience with transitions of care.
While the survey indicated that most patients
understood discharge instructions and were
receiving needed services, the pain points
identified in their responses aligned with those
found in the literature-managing complex
medication regimens, inadequate education,
problems managing symptoms, and limited
follow-up. The findings from the survey can
be found in a separate UHF report, Pain
Points Along the Journey from SNF to Home:
Patient and Caregiver Perspectives.

At the end of the first year of the collab-
orative, the SNFs had developed targeted
intervention plans that included their aim,
multidisciplinary team, actions, and measures.
The focus of the second year was implement-
ing steps of change, making refinements, and
collecting data for measures to assess impact.
Interventions were largely aimed at providing
patient and caregiver education that addressed
their specific needs, better coordination and
communication among the care team and with
the patient and caregiver during the discharge
planning process, and providing consistent
post-discharge follow-up that was timely and
relevant. To support our SNF participants

in their work, we continued to host learning
sessions, coaching from UHF staff and advi-
sory faculty, and opportunities to learn from
peers. In addition to learning sessions focused
on topics such as patient education techniques
and medication management in nursing
homes, sessions were devoted to reporting on
the progress of interventions and sharing les-
sons learned. The coaching calls provided the
SNFs with technical assistance related to the
intervention approach, measure selection, data
review, and feedback on how best to navigate

2 The teach-back method is a way of checking understanding by asking patients to state in their
own words what they need to know or do about their health. It is a way to confirm that you have
explained things in a manner your patients understand.

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT 3
organizational and implementation chal-
lenges. In addition, a digital resource library
was developed to assist SNFs as they worked
on improving their processes. The resources
provided are included in Appendix C. Given
the continued impact of the pandemic, some
participants had to adjust their project plans

to address challenges that the pandemic posed.

The eight participating SNFs implemented
facility-specific interventions based on their

own quality improvement plans, as well

as some common initiative-wide interven-
tions and cross-cutting measures designed to
address opportunities for improvements across
all eight facilities (described in a separate
section below). The SNFs in our collabora-
tive varied greatly in terms of size, location,
communities served, and resources; as a result,
their areas of focus and their solutions to
problems varied.

Facility-Specific Interventions

Improving Medication
Education Before Discharge

One facility identified that its medication
education process during discharge planning
was often inconsistent and did not involve
all members of the team. Due to its smaller
size and staffing challenges, a nurse was not
always available to educate patients on their
medications before discharge, which left
patients and caregivers less confident about
how and when to take medications properly.
The SNF's aim was to improve understanding
of discharge medications and treatments

for 85% of the short-stay patients before
discharge.

The facility worked to improve its process
for teaching patients and caregivers about
their discharge medications by having the
nurse review medication with patients and
caregivers within three days of admission
and again before discharge. The education
provided at discharge also involved the
patient's family. A social worker assessed the

patient's understanding by including questions
related to medication education during the
follow-up calls that were conducted within 72
hours of discharge. The patients' reporting of
understanding of medications improved from
60% before the intervention to 94% after

it.> The SNF also described patient anecdotes
where the questions posed during the post-
discharge follow-up calls allowed the facility
to address problems such as difficulty picking
up medications.

Team involvement across disciplines in
medication education was crucial, especially
having a nurse discuss the medications in
detail with the patient before discharge. They
also identified that frequently patients were
not taking their medications properly before
admission. Additionally, the SNF found that
some patients were having challenges picking
up medications once they were home, so it
was important to address that during the
follow-up phone calls to ensure that patients
had access to their needed medications. In the
future, the SNF staff plan to conduct an initial

3. This facility had, on average, a small number of subacute discharges each month (n < 10).

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT
review of medications that the patients use at -_ green, yellow, and red color-coding system to

home and assess their medication knowledge. _ help direct patient responses.* The educators
at this SNF used the Zone Tools for chronic
Improving Patient pulmonary obstructive disease, diabetes, heart
Education on Chronic IIIness disease, heart failure, kidney health, and
Self-Management stroke to help provide tailored educational

materials to the patient. Additionally, the
SNF made use of nursing students who had

. os . participated in clinical rotations on-site
diseases and the potential side effects of high- before the COVID-19 pandemic to provide

tisk medications. There was i, established virtual education sessions to patients.
vide um he stal to Topics for these sessions included diabetes
Provide to the patients management, pain management, heart failure

and caregivers that management, and hypertension management.

his encouragement, the consistently addressed The SNF also engaged its on-site pharmacy
condition-specilic Issues + conduct medication reconciliation with

patient was able to use il dicati
her subcutaneous glucose whe SNe arene the physician 48 hours before discharge and

monitor in front of me and . ; conduct education with the caregivers before
to improve patient .
another floor nurse and she P P . discharge.
knowledge of chronic
was able tocheckher blood .
illness self-management
sugar. [The patient] was so .
. . with the use of teach-
happy.... She was jumping out

; . k fe % of th
of her chair. She said to me, pac or 90 70 0 me
"you are my hero," and she short-stay patients provided by the nursing students, use of teach-

hugged me. It was a proud before discharge. back was successfully documented for 89% of
moment for me. | have a . patients. On average, each patient had at least
The SNF's transitional two virtual educational sessions, and 72% of
educators adopted the the patients received medication education.
teach-back method to Overall, the SNF reported positive anecdotal
provide chronic illness feedback from patients about the use of
self-management to nursing staff providing virtual education, but

P - dur ng their | no formal data were collected on patients'
stay. The transitiona experience of it.

educators used Zone
Tools, a set of resources designed to aid in
patient self-management by helping identify
common symptoms, warning signs, and the
appropriate patient response, using a simple

Another facility found that patients were not
always well equipped to manage their chronic

"Please give many thanks
to the student nurse. With

The use of the Zone Tools increased during
the intervention period, from 17% to 77%.
During the month that virtual education was

feeling that | did something
that she wanted and | learned
a new technology. Now | don't
have to prick her fingertip
four times a day, just scan her
thigh monitor. |am so happy."

The facility found that every department's
involvement in process mapping helped
identify strengths and gaps during care
transitions, which ultimately led them

4 Health Services Advisory Group (HSAG) developed and published a set of downloadable resources
called Zone Tools, intended to help patients manage various health conditions. The full set of
resources (in English and Spanish, with some in Armenian as well) may be found on the HSAG
website: https:/Awww.hsag.com/zone-tools/

With HSAG's permission, UHF commissioned translations of some of these tools into Albanian,
Italian, Russian, and Chinese; they are available on a resource page of UHF's website that
accompanies this toolkit: https://uhfnyc.org/our-work/initiatives/quality-institute/snf-learning-
collaborative/snf-resources/,

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT 5
to bolster the chronic disease education
provided to patients and caregivers. The chief
quality officer, chief nursing officer, nursing
administrator, and transitional educators'
involvement in approval of chronic illness
self-management tools and documentation
guidelines was critical to developing and
sustaining the intervention. Specifically for
the Zone Tools, the SNF developed scripts

on how to use them, prepared a process

for documenting their use, and provided

staff with real-time positive feedback via

text. In addition, many tests of change were
conducted to improve the interventions (e.g.,
use of built-in microphones for patients and
student nurses for virtual education). The

use of nursing students for virtual education
was beneficial for the patients given the
students' ability to spend more time with each
patient. The students also benefited from this
meaningful learning experience on how to
support patient and caregiver needs during the
transition home. One of the challenges with
the virtual education sessions is sustainability
given the dependence on nursing education
students who rotate at the SNF and are there
for only a short time.

Streamlining the Discharge
Planning and Communication
Process to Improve Patient
Preparation for Discharge

One facility identified gaps in accountability
for the patient's discharge plan and found that
communication between staff members about
activities to meet the
patients' needs was

The SNF repurposed an interdisciplinary
discharge summary for the discharge planning
meetings to close the loop on patient
education and follow-up. They assigned a
point person, the assistant director of nursing,
to oversee following up with the different
disciplines. The tool included information
regarding the diagnosis, therapy plan, durable
medical equipment needs, activities of daily
living, referrals, and other notes pertinent

to the discharge plan. Initially the assistant
director of nursing reviewed and assessed each
patient's educational needs upon admission;
later this was shifted to the medical director.
The interdisciplinary team was also alerted
when families were coming to the facility

for education so that they could plan their
teaching sessions in advance. The SNF also
developed a set of educational resources to
provide patients with materials across all
disciplines (nursing, social work, physical

and occupational therapy). To assess the
intervention, the SNF revised its pre- and
post-discharge surveys to focus on the most
important information that needed to be
addressed before discharge, and then assessed
whether those needs were met.

The pre-discharge and post-discharge

surveys indicated overall satisfaction with
meeting the patient's educational needs.

Over a four-month period, 91% of patients
indicated pre-discharge that they were given
educational materials and/or teaching about
their diagnosis and managing at home. This
increased to 100% post-discharge, suggesting
that gaps identified by the pre-discharge

survey during the rehab stay were successfully
addressed before discharge.

"The discharge planning
meetings are good-the key
piece is we put everything in

writing, including what needs
to be followed up."

often inconsistent.
The SNF's aim was
to improve staff
accountability and
engagement during
the discharge process
and to implement a staff communication tool
to better coordinate patient and caregiver
education and follow-up.

The SNF found that a weekly review of a tool
that identifies all patients, their needs, and
their discharge plans has helped improve team
communication and close the loop on patient
education and needs, This review, coupled
with designating a point person for follow-up,
has also been crucial to ensuring that there

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT 6
aren't any gaps in communication. The
SNF's use of a comprehensive pre-discharge
survey has enabled it to identify and address
patient needs promptly. The SNF has also
automated the pre-
and post- discharge
surveys via the use
of SurveyMonkey®,
which has made
analysis of the
results much more
expedient. The SNF

the content of the patient education video
scripts, and staff members narrated the videos.
The videos covered fall prevention, use of
medical equipment, diabetes care, managing
hypertension, managing the transition to the
SNF, skin care, managing medications, meal
preparation, heart failure, recovery after hip
and knee surgery, the importance of home
care, and making the transition to home. The
videos were deployed in multiple ways-via
iPads on the floor, via a television channel
dedicated to patient education, and on the

"We had one issue with one

of the patients [during the
follow-up phone call] over the
weekend-her legs looked
very swollen and we were able
to reach out to her physician
and he was able to do the

follow-up and that worked out

plans to continue

its participation

in person-centered
projects that continue
to place the patient and the caregiver as the
focus of any intervention.

awesome."

Supporting Patient Education
with Video Technology

1. Developing Videos In-House

At one facility, patient education materials
were not always clear to the patients and
caregivers and did not meet their needs. This
included having a clear understanding of their
condition as well as potential warning signs

and symptoms that could arise after discharge.

The SNF's aim was to ensure that all short-
stay patients received better patient education
with teach-back techniques and improved
access to engaging patient education materials
using videos. The goal was to enhance the
patient education system so patients could
receive effective and continuous educational
resources at their convenience, helping them
stay actively engaged in managing their own
conditions during and after their stay.

The facility's focus for the intervention was
creating in-house educational videos that were
easy to understand and involved the facility
staff. An interdisciplinary team developed

SNF website and YouTube channel so that
patients and caregivers could access the videos
at their convenience after discharge. The SNF
assessed the intervention by administering

an open-ended patient survey to assess
perceptions of the videos' educational value.

There was positive feedback from the survey
on the use of the educational videos; patients
felt they were "very informative," and "very
clear and very helpful on how to use the
equipment." This intervention facilitated

both patient and staff engagement-staff were
actively engaged in developing the videos, and
patients were able to see the staff members
who cared for them. In addition, the facility
tracked which videos were being watched.
While there was widespread use of the fall
prevention video, limited utilization of the
condition-specific videos did not reflect the
education gaps that were identified early in
the project. This project initially involved the
executive staff, but as the project progressed
the SNF found that it was an opportunity to
have front-line staff step up and participate.
The SNF plans to add more topics to the
video collection and will actively train nursing
staff on how best to use the videos to reinforce
patient education. In the future, the SNF plans
to offer patients a complimentary primary care
follow-up visit within seven days of discharge
to ensure better care continuity.

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT 7
2. Using a Video Library from an
Outside Source

Another facility took a different approach,
after finding that patients were not always
engaged in their own care and that they
sometimes lacked a clear understanding of
their condition and what they would need to
do when they went home. Their needs were
not identified in a systematic way within the
first few days of admission. The SNF's aim
was to identify patient education needs for
90% of short-stay patients within the first
few days of admission and provide additional
education before discharge via videos.

The SNF's intervention was to implement
video-based educational technology using an
external vendor that had a comprehensive
educational library. The SNF's leadership
selected over 300 topics to include in the
educational offerings to the patients. In
addition, the SNF identified gaps in patient
educational needs and utilized the information
to identify appropriate video content within
the first three days upon admission. Staff
would then take tablets to the patient's
bedside for them to view the educational
videos.

The SNF conducted a pre-discharge survey
on the video educational materials and asked
related questions during the post-discharge
follow-up phone calls. On average, 28% of
patients reported they watched an educational
video via the tablet. However, upon hiring a
public health intern who provided additional
resources for this effort, 75% of patients had
utilized the educational videos based on 1
month of data. Patient feedback on the videos
was generally positive-though patients with
technological limitations or hearing issues

made only limited use of the video technology.

The facility found it helpful to have
interdisciplinary huddles to organize the
patient's educational needs and specifically

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT

discuss the video content during discharge
planning meetings, tailoring the video
selection for each patient. A broad challenge
identified, especially given the initial low
uptake in viewing of the videos, was that
video technology was not appropriate

for all their patients and other forms of
educational materials (e.g., written material
and demonstrations) were needed as well.
The SNF also plans on meeting with the
patients more than twice for education before
discharge to help with their comprehension
and retention of the material. The SNF

will also incorporate additional types of
educational material via brochures, handouts,
and signage throughout the facility.

Increasing Participation in the
Discharge Planning Process

At one facility, a lack of communication
among team members, patients, and caregivers
was causing delays and gaps in the discharge
planning process. The SNF's aim was to better
coordinate and communicate the discharge
plan with the involvement of the patient

and caregiver at a discharge planning care
conference.

The SNF's intervention was to implement

a weekly meeting to address each patient's
discharge planning needs. It included an
interdisciplinary team to review the proposed
discharge plan of care with patients and
caregivers, providing them an opportunity

to ask questions and bring up any previously
unidentified needs. Each meeting covered all
the patients slated for discharge the following
week.

Over a seven-month period, on average

98% of patients being discharged to the
community and 96% of caregivers attended
the meeting. Caregivers attended the discharge
planning meetings virtually when needed due
to COVID-19. The meeting provided staff

an opportunity to better coordinate patient
care in advance of discharge, and to allow
ample time for follow-up questions from
patients and caregivers. Efforts were made to
include the specific rehab and nursing staff
working with the patients, as they were the
most familiar with the patients' functional
capabilities that needed to be considered in
planning a safe discharge to home.

Cross-Cuttin
Initiative-W1|

In addition to the facility-specific interventions
described above, UHF identified some
common, cross cutting issues for all eight
participating SNFs and suggested measures
for all of them to collect. These initiative-
wide interventions covered patient education,
consistent follow-up with patients and
caregivers after discharge, and other common
areas of post-discharge concern regarding
medications and concerning signs and
symptoms that they may experience at home.
These measures are provided below:

e Teach-back of discharge education
documented by nursing

¢ Follow-up phone call conducted within 72
hours of discharge

¢ Survey questions asked during post-
discharge follow-up phone call:

® "Staff explained what medication they
should take and how and when to
take it"

® "During discharge planning, I received
information I could understand about
what symptoms or problems I may
experience"

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT

The SNF found some initial resistance toward
the discharge review meetings from the team,
since some ended up being very time-intensive.
In addition, the SNF faced challenges due

to staffing during the COVID-19 pandemic.

In addition to discussing discharge planning
needs, the meeting was also used as a forum
to provide instruction and education to the
patient and family and address unresolved
questions and issues.

Measures and
e Outcomes

The two statements that all facilities asked
during the post-discharge call were taken
directly from the patient and caregiver survey
conducted in 2020. We chose to include
these questions because the 2020 survey
results indicated important opportunities for
improvement for all participants.

The following charts show individual
facilities' performance on the initiative-wide
cross-cutting measures, as well as the overall
aggregated performance. Some caveats should
be considered when analyzing and comparing
the pre- and post-intervention results. For

the first measure considered, pre-intervention
data were not available. Pre-intervention
data were self-reported by patients, and
post-intervention data were self-reported by
facilities, based on patient responses.

The patient and caregiver survey utilized

a multi-modal approach-surveys were
administered online, by written survey, and by
phone; post-intervention data were collected
by phone only.

Additionally, we recognize that patients may
respond to questions differently when they are
called directly by facility staff as opposed to a
caller from a market research company, with
whom results would be anonymous.

Teach-Back from Nursing Staff

The overall rate of teach-back across the
facilities was 85%. While pre-intervention
data are not available for teach-back, we
know that not all facilities at the beginning of
the collaborative used teach-back techniques
to educate patients about their care by
ensuring that staff were communicating in a
way in which patients could understand.

One of the learning collaborative sessions
focused on how to conduct teach-back and
provided the facilities with the tools to teach
their staff. Teach-back documentation varied
across the facilities-some recorded it in the
EMR while others recorded it in nursing
progress notes.

Follow-Up Phone Calls

The overall rate for follow-up phone calls
increased from 59% to 74%; seven of

the eight facilities improved this rate. The
follow-up calls were an important intervention

 

100%
80%
FIGURE 1. PERCENT OF PATIENTS

WITH DOCUMENTED TEACH-
BACK FROM NURSING STAFF

60%
40%
20%
Post-Intervention Data 0%
(June - September 2021}

100%

FIGURE 2. PERCENT OF PATIENTS
REACHED BY A FOLLOW-UP
PHONE CALL

80%
60%

Pre-Intervention Data
(August - December 2020)

Post-Intervention Data
(June - September 2021}

x

FIGURE 3. PERCENT OF PATIENTS
REACHED WITHIN 72 HOURS OF
DISCHARGE

60%

40%

20% LI
0

40%

20%

100%
0, a
Post-Intervention Data o%

80%
(June - September 2021} O
rg

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT

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Ww

yD ie »
< < XN < & <
on 2 Se x © ~~ S
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10
to assess whether patients felt prepared to

be home post-discharge and provided an
opportunity for patients to ask the SNF staff
any follow-up questions regarding their care.

Facilities were encouraged to develop
processes to conduct the post-discharge
follow-up call within 72 hours of discharge to
ensure that any issues immediately following

patients within 72 hours and are very proud
of that progress, and actually found it easier to
connect with people when [the calls are] done
sooner.

Patient Understanding of
Medications and Symptoms

Patient understanding of prescribed

discharge could be addressed. Overall, 74%
of the successful post-discharge calls occurred
within 72 hours, with considerable variation
among facilities. Staff members from one SNF
noted that they "have had success in reaching

100%
FIGURE 4. PERCENT OF PATIENTS
REACHED WHO SAID STAFF EXPLAINED
WHAT MEDICATION THEY SHOULD TAKE
AND HOW AND WHEN TO TAKE IT

80%
60%

40%
Pre-Intervention Data

(August - December 2020) 20%

Post-Intervention Data
(June - September 2021} 0%

FIGURE 5. PERCENT OF PATIENTS 100%
REACHED WHO SAID THAT DURING
DISCHARGE PLANNING THEY

RECEIVED INFORMATION THEY COULD
UNDERSTAND ABOUT WHAT SYMPTOMS

OR PROBLEMS THEY MAY EXPERIENCE

80%
60%
40%

Pre-|ntervention Data
(August - December 2020)

20%

0,
Post-Intervention Data 0%

(June - September 2021}

medication increased from 57% to 98%,
and patient understanding of symptoms

and problems they may experience at home
increased from 70% to 93%. Both measures
improved at all eight facilities following the

interventions.
A B Cc D E F G H Total
A B Cc D E F G H Total

Notes on the charts in this section: On the x-axis, A through H represent individual anonymized participating facilities.

The sample sizes varied among facilities and between pre- and post-intervention surveys; pre-intervention, the number of
respondents ranged from 8 to 82 at varying facilities (total of 263 across all facilities); and post-intervention, while generally
larger, the numbers of respondents ranged from 5 to 147 (total of 721 across all facilities for the "follow-up phone call" question

and 532 for the "signs and symptoms' question).

Note that on Figure 4 and 5, Facility A showed improvement but also had a small number of responses.

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT Tl
Challenges

Effectively meeting the transition needs of
short-stay SNF patients must be considered

in the much broader context of the challenges
facing our entire long-term care system. Many
of the barriers identified in the interventions
described above will be difficult to overcome
in the long-term without also addressing
existential challenges in the system. It is
widely acknowledged that there has been
underinvestment in long-term care in the U.S.,
which has been highlighted and magnified
during the COVID-19 pandemic. A key issue
is the fragmented system for financing of
nursing home care. Medicaid is the largest
payer for long stay nursing home care;
however, Medicaid payments for long-term
patients often fall below the cost of providing
care for these frail older adults. Medicare is

a more generous payer for beneficiaries who
are admitted to the nursing home for a short
stay for rehabilitation following surgery or
illness; therefore, the financial stability of
many nursing homes rests on their ability to
admit enough Medicare short-stay patients

to subsidize the care of long-stay Medicaid
residents.' As a result, the shrinking number
of short-stay nursing home patients during the
pandemic has put a significant financial strain
on many nursing homes.

Adequate staffing is key to providing high-
quality care, and staff shortages and high
turnover have long been problematic for
nursing homes. Staffing structures can be
hierarchical with direct caregivers, many of

whom are paid near the minimum wage and
hold little power to effect change at their
employer.® This challenging environment
for staff has contributed to chronically high
turnover and staffing shortages which have
only been exacerbated during the pandemic.
Nationally, staff turnover rates for certified
nursing assistant, a large component of

the nursing home workforce, jumped to a
staggering 51.4% in 2021, and the turnover
for all nursing home employees."

Securing adequate staffing is even more
problematic in underresourced nursing
homes located in economically disadvantaged
neighborhoods serving diverse communities,
several of which participated in our
collaborative.

The COVID-19 pandemic affected our
collaborative in numerous ways. During the
initial months of the collaborative, SNFs

were overwhelmed with the challenges of
caring for large numbers of patients with
COVID, restricted visitation, staff illness and
resulting shortages, lack of personal protective
equipment, and numerous and constantly
changing regulatory requirements. While the
number of COVID cases declined during the
first half of 2021, our SNFs continued to care
for frail, elderly COVID patients, while also
prioritizing the distribution of vaccines to
patients, staff, and the communities they serve.
Family visitation remained restricted due to
ongoing COVID cases, creating persistent
challenges for conducting care conferences,
education, and transition planning.

5 Grabowski, David. August 2020. Strengthening Nursing Home Policy for the Postpandemic World:
How Can We Improve Residents' Health Outcomes and Experiences? The Commonwealth Fund,

Issue Brief.

6 Grabowski, David. August 2020. Strengthening Nursing Home Policy for the Postpandemic World:
How Can We Improve Residents' Health Outcomes and Experiences? The Commonwealth Fund,

Issue Brief.

7 Hospital and Healthcare Compensation Service, 44th annual report.

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT 12
Participating facilities also faced tremendous
COVID-related staffing challenges due to
unplanned staff departures, and they had

to adjust to manage existing priorities with
even fewer resources and team members
than usual. The tremendous impact of staff
illness, resignations, early retirement, and
burnout cannot be overstated. In the early
months of the pandemic, some SNFs reported
having difficulty arranging home health care,
and some patients were hesitant to have
home health staff in their homes, resulting in
additional challenges for transitions of care.

Lessons Learned

When we began the collaborative, our team
anticipated that many SNFs would focus
their interventions on improving transitions
to home by identifying and addressing social
needs and forging closer collaboration

with community-based organizations to
ensure these needs were met. While our
SNFs acknowledged the importance of
screening for social needs and connecting
patients with resources in the community,
we quickly learned that much work needed
to be done within the four walls of the SNF
before these larger outside issues could

be tackled. Communication breakdowns,
lack of standardized discharge planning
processes, and inadequate patient and family
education were problems that led to patients
lacking confidence and skills to manage
their conditions at home; such issues were
more realistically achievable than broader
external challenges within the scope of this
collaborative. The SNFs were all able to
identify opportunities for improvement in
their internal discharge planning processes
that could benefit the patients and families
they serve.

In addition, short-stay volumes were low
because of widespread curtailment of elective
procedures-and, in some cases, patient
hesitancy to be admitted to a nursing home.

In light of these numerous challenges, the
efforts of nursing home staff to care for
patients during the pandemic has been nothing
short of heroic. Despite these challenges, the
SNFs remained committed to participation

in the collaborative, demonstrating their
commitment to improving transitions of care
for the patients and families they serve.

Four important lessons emerged from the
collaborative:

1. Value of process mapping. First, most of
our participants expressed that they benefited
greatly from the use of the process mapping
exercise that was conducted early in the
collaborative. Process mapping, when done
with the interdisciplinary team and front-line
staff, enabled SNFs to better understand the
gaps in their discharge planning process and
develop specific interventions to address them.
The SNFs reported that it was particularly
helpful to understand each discipline's role

in the process and where communication
between the members of the team can break
down. For some of the SNFs, it was the first
time that they had used this tool, and they
expressed the intent to utilize process mapping
in all future quality improvement efforts.

2. Standardization of processes. As a result of
the process mapping, the teams were able to
identify improved workflows, and specify staff
roles and accountability for key processes. By
standardizing processes such as conducting

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT 13
the follow-up phone calls using scripts, and
identifying educational needs upon admission,
more consistent and effective education and
post-discharge follow-up could be provided.

3. Interdisciplinary nature of discharge
planning. Before the initiative, some facilities'
discharge planning was considered to be in the
purview of social work, and involvement of
the interdisciplinary team was not prioritized.
Increased participation of the interdisciplinary
team in identifying and addressing patients'
educational needs was a valued outcome of
the collaborative. Utilization of various modes
of education-verbal, written, and video-
with emphasis on the use of the teach-back
method to ensure that staff communicated
clearly in a way that patients and families
could understand, resulted in patients
reporting better preparation for return home.

4. Early and tailored contact after discharge.
While most facilities were conducting post-
discharge calls before the initiative, many were
not conducting those calls within 72 hours.
The facilities learned that early identification
of issues helped avert exacerbation of
symptoms and rehospitalization. In addition,
they found that including questions about
the preparation and education that patients
had received during their stay helped them
to evaluate the success of these efforts. Some
of our SNFs began to utilize pre-discharge
surveys that served as an effective tool to
identify gaps in patient education that could
be addressed before discharge.

A list of questions used for the pre- and post-
discharge surveys is provided in the resource
section this toolkit in Appendix D.

Future Directions and Policy

Implications

Our project focused on small interventions
aimed at improving discharge planning,
patient education, and post-discharge follow
up for patients being discharged home from
a short stay in a skilled nursing facility. In
this project, we saw marked improvement

in the SNFs' ability and commitment to
complete timely post-discharge follow-up
calls and to ensure that patients' needs are
met in the immediate post-discharge period
as they go home. However, there are systemic
challenges that need to be addressed as

part of any large-scale effort to improve the
quality of care for older adults going home
from a SNF, Long-term care in this country
is inadequate to support the needs of older
adults, and both facility-based care and

home- and community-based services (HCBS)
are underfunded. As a result, coordination
with primary care in the community and

the strengthening of relationships with
community-based organizations providing
social services are difficult for underresourced
nursing homes with ever-increasing staffing
challenges, which have only been exacerbated
by the pandemic. The difficulties that patients
experience when transitioning home from care
in a skilled nursing facility are only a small
example of the lack of a comprehensive and
sustainable long-term care strategy.

While there are many challenges that need
to be addressed when a patient is discharged
from an acute care hospital to a SNE, a "warm

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT 14
handoff" of the patient to the receiving
health care provider is possible and has been
identified as a successful transition of care
strategy. This type of handoff to a health
care provider rarely occurs when a patient

is being discharged home. In some cases,
SNFs with strong connections to home health
services can facilitate this handoff. While
SNFs make efforts to ensure that patients
have visits with their primary care physicians
arranged before discharge, this can often

be challenging and delayed, as care in the
community may be fragmented and it may
not be clear who is chiefly responsible for
managing the patient's care. This uncertainty
may exacerbate problems being experienced
by frail elder patients with multiple chronic
conditions being discharged from the SNE
Such fragmentation often contributes to a lack
of coordinated care, inaccurate medication
reconciliation, and resulting medication
management problems for the patients when
they return home. Value-based payment
methodologies, especially for Medicare
patients, provide financial incentives for SNFs
with low rates of rehospitalization; however,
SNFs with limited staff are likely unable

to devote scarce resources to the ongoing
management of patients' complex needs after
discharge.

While there has been an increase in the
percentage of Medicaid dollars spent on
HCBS, including recent state and federal
investments, navigating the various programs
is complicated and remaining gaps in services
largely fall to family caregivers who may not
have the capacity to manage the patient's
complex care at home. Further investment

in home- and community-based services is

needed, as well as funding mechanisms to
ensure the coordination of medical and needed
social services. It will be essential that patients,
caregivers, advocacy groups, providers,
payers, and policymakers work together to
develop and fund services that further support
the needs of frail elderly patients across the
continuum of care and facilitate coordinated
care to ensure their ongoing health and well-
being in the community.

Acknowledgments

This work was supported by the Mother
Cabrini Health Foundation.

We would like to acknowledge the hard
work of the eight SNFs that participated in
our learning collaborative and the survey.
We appreciate their commitment to this
project, especially during this challenging
time of the COVID-19 pandemic. From
UHE, we would like to thank Anne-Marie
Audet, Kevin Mallon, and Lynn Rogut of
UHF for their important contributions to
the collaborative's work, as well as Janice
Dabney and Dr. Anthony Lechich, who
served as external experts and faculty for the
learning collaborative. We greatly appreciate
the participation of the Greater New York
Hospital Association in this initiative. Many
thanks also go to Mark Kator and the
members of our Advisory Group for sharing
their expertise.

From the UHF Communications team, Miles
P. Finley provided editing and design support,
James Andrews prepared the accompanying
online resources, and Catherine Arnst assisted
with report dissemination.

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT 15
 

Appendix A: SNF Profiles

 

Total # of Short-

 

Skilled Nursing Facility Stay Beds County
Ferncliff Nursing Home 40 Dutchess
Gurwin Jewish Nursing and Rehabilitation Center 80 Suffolk
Jamaica Hospital Nursing Home 80 Queens
Parker Jewish Institute for Health Care & Rehab 180 Nassau
Schulman and Schachne Institute for Nursing and Rehabilitation 66 Kings

Sea View Hospital, Rehabilitation Center and Home 40 Richmond
Terence Cardinal Cooke Health Care Center 102 New York
The New Jewish Home, Sarah Neuman 56 Westchester

 

Appendix B: SNF to Home
Collaborative Topics
(July 2020 to December 2021)

Year 1

Learning Session 1: Family Caregivers and Transition Planning

Learning Session 2: Introduction to the Model for Improvement & Process Mapping
Learning Session 3: SNF Presentations of Process Maps

Learning Session 4: Addressing Patient's Health-Related Social Needs: The Role of
Community Based Organizations

Learning Session 5: Improving Nursing Home Discharges Back to the Community &
SNF Presentations of Proposed Interventions

Learning Session 6: Patient and Caregiver Survey Results Overview Year 2
Learning Session 7: Improving Transitions through Patient Education

Learning Session 8: Nursing Homes and Medication Management: Strategies for
Success

Learning Session 9: SNF Presentations on Progress of Interventions
Learning Session 10: Age Friendly Health Systems & The 4 M's in Nursing Homes
Learning Session 11: Successes and Challenges of Intervention Implementation

Learning Session 12: Final Presentations from SNFs on Intervention Results

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT 16
Appendix C: Resource Library for
SNF to Home Collaborative

These resources were provided to participants on a private website during the project;
they are also now available on UHF's public website, here: https://uhfnyc.org/our-work/
initiatives/quality-institute/snf-learning-collaborative/snf-resources/

Improve Discharge Planning Processes
Care Transitions Toolkits

Society of Hospital Medicine - Project BOOST: Implementation Guide to Improve Care
Transitions
https:/Awww.hospitalmedicine.org/globalassets/professional-development/professional-
dev-pdf/boost-guide-second-edition.pdf

AHRQ - Care Transitions from Hospital to Home: IDEAL Discharge Planning Training.
https:/Awww.ahrq.gov/patient-safety/patients-families/engagingfamilies/strategy4/
index.html

Communication Tools

Always Use Teach back
http:/Awww.teachbacktraining.org/nome

AHRQ - Health Literacy Universal Precautions Toolkit
https:/www.ahrgq.govw/health-literacy/improve/precautions/index.htm|

UNC - The Teach Back Method Videos
https://hsl.lib.unc.edu/health-literacy/videos-tutorials/

Discharge Checklists

For Patients/Families:

CMS - Your Discharge Planning Checklist
https:/www.medicare.gov/Pubs/pdf/11376-discharge-planning-checklist.pdf

RW5IF - Discharge Preparation Checklist
https:/www.rwif.org/en/library/research/2013/01/care-about-your-care-discharge-

checklist---care-transition-plan.html

HealthCentric Advisors - My After Nursing Home Care Plan
https://nealthcentricadvisors.org/wp-content/uploads/2019/08/AfterCarePlan.pdf

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For Staff:

AHRQ - IDEAL Discharge Planning Checklist
https:/Awww.ahraq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/
engagingfamilies/strategy4/Strat4_Tool_l_IDEAL_chklst_508.pdf

Society of Hospital Medicine - Project BOOST. The 8P Screening Tool Identifying Your
Patient's Risk for Adverse Events After Discharge
https:/www.hospitalmedicine.org/globalassets/clinical-topics/clinical-pdf/8ps_
riskassess-l.pdf

HealthCentric Advisors - Re-engineered Discharge for SNFs Checklist
https://nealthcentricadvisors.org/wp-content/uploads/2019/08/Pt-Level-RED-Checkilist.
pdf

Medication Management Tools

For Staff:

Eric Coleman - Medication Discrepancy Tool
https://caretransitions.org/wp-content/uploads/2015/08/MDT.pdf

For Patients/Families:

UHF Next Step in Care - Medication Management Form
https:/Avwww.nextstepincare.org/Caregiver_Home/Medication_Management_Guide/

AARP - Family Caregiver's Video Guide to Managing Medications
https:/Avww.aarp.org/ppi/info-2016/family-caregiver-video-guide-to-managing-
medications.htm|

Social Needs Screening Tools and Assessments

Health Leads - Social Needs Screening Toolkit
https://nealthleadsusa.org/resources/the-health-leads-screening-toolkit/

CMS - The Accountable Health Communities Health-Related Social Needs Screening

Tool
https://innovation.cms.gov/files\worksheets/ahcm-screeningtool.pdf

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Enhancing Patient Education

Disease-Specific Information

Alzheimer's Disease
NIA -- Alzheimer's Caregiving: Changes in Communication Skills

English - https:/www.nia.nih.gov/health/
alzheimers-caregiving-changes-communication-skills

Spanish - https:/www.nia.nih.gov/espanol/
cambios-habilidades-comunicacion-relacionados-enfermedad-alzheimer

Alzheimer's Association - Caregiver Health (various topics on caregiver health)
https:/www.alz.org/help-support/caregiving/caregiver-health

Alzheimer's Association - Care Training Resources (video courses in English and some
in Spanish on warning signs, understanding the disease, conversations, effective
communication, healthy living, legal and financial planning, different stages)
https://www.alz.org/help-support/resources/care-training-resources

Atrial Fibrillation
AHA - What is A Fib?

https:/www.heart.org/en/health-topics/atrial-fibrillation/
what-is-atrial-fibrillation-afib-or-af

AHA --A Fib Symptom Tracker
https:/Awww.heart.org/en/health-topics/atrial-fibrillation/
what-are-the-symptoms-of-atrial-fibrillation-afib-or-af

Chronic Kidney Disease

NIDDK - Chronic Kidney Disease
https:/Awww.niddk.nih.gov/health-information/kidney-disease/
chronic-kidney-disease-ckd/all-content

NIDDK - Eating Right for Chronic Kidney Disease
https:/Awww.niddk.nih.gov/health-information/kidney-disease/
chronic-kidney-disease-ckd/eating-nutrition

ARA - Kidney Disease 101
https:/Wwww.americanrenal.com/for-patients-and-caregivers/what-you-need-to-know#

ARA - Nutrition
https:/Awww.americanrenal.com/for-patients-and-caregivers/nutrition-and-wellness

Kidney School (learning modules in English and Spanish with videos and educational

guides)
https://kidneyschool.org/

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT 19
Chronic Obstructive Pulmonary Disease (COPD)

ALA - My COPD Action/Management Plan (English and Spanish)
http://action.lung.org/site/DocServer/ala-copd-management-plan.pdf

ALA - How to Use a Nebulizer and How to Clean a Nebulizer video (video)
https:/Awww.lung.org/lung-health-diseases/lung-disease-lookup/copd/
patient-resources-and-videos

Dementia
CaringKind - Family Caregiver Guide
https:/Awww.caringkindnyc.org/_pdf/CaringKind_FCG-English_webv.pdf

Diabetes

ADA - What is Diabetes?
https:/Awww.diabetes.org/diabetes

ADA - Understanding AIC
https:/Awww.diabetes.org/alc

ADA - Prediabetes
https:/Awww.diabetes.org/diabetes-risk/oprediabetes

ADA - Healthy food choices
https:/www.diabetes.org/nutrition/healthy-food-choices-made-easy

ADA - Online Community
https://community.diabetes.org/home

Heart Failure

AHA Rise Above Heart Failure - Toolkit (includes patient discharge checklist, lifestyle
changes, medication, symptom monitoring)
https:/Awww.heart.org/en/health-topics/heart-failure/heart-failure-tools-resources/
rise-above-heart-failure-toolkit

AHA Rise Above Heart Failure - Self Check Plan (English and Spanish)
https:/Awww.heart.org/-/media/Files/Health-Topics/Heart-Failure/HF-Symptom-Tracker.
pdf

Parkinson's Disease

Parkinson's Foundation - About Parkinson's Disease
https:/Awww.parkinson.org/understanding-parkinsons/what-is-parkinsons

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT 20
Stroke

AHA/ASA - About Stroke
https:/Avww.stroke.org/en/about-stroke

AHA/ASA - Risk Factors for Stroke (English and Spanish)
https:/Awww.stroke.org/en/about-stroke/stroke-risk-factors

AHA/SASA - Caregiver Guide to Stroke
https:/Awww.stroke.org/-/media/stroke-files/caregiver-support/caregivers-guide-to-
stroke/caregiverguidetostroke_2020.pdf?la=en

AHA/SASA: Your Stroke Discharge Checklist
https:/wwwstroke.org/-/media/stroke-files/stroke-resource-center/recovery/patient-
focused/stroke-discharge-list-for-patients-and-caregivers-ucm_463810.pdf?la=en

Wound Care

AARP - General Principles of Wound Care (video)

English - https:/videos.aarp.org/detail/video/5597247508001/family-caregiving-series:-
general-principles-of-wound-care-%E2%80%94-aarp

Spanish - https://videos.aarp.org/detailvideo/5593516484001/serie-para-cuidadores-
familiares:-principios-generales-para-curar-una-herida-%E2%80%94-aarp

Falls

NIA - Prevent Falls and Fractures (general explainer for patients)
English - https:/Awww.nia.nih.gov/health/prevent-falls-and-fractures
Spanish - https:/Awww.nia.nih.gov/espanol/prevenga-caidas-fracturas

NIA - Fall-Proofing Your Home
English - https:/Awww.nia.nih.gov/health/fall-proofing-your-home
Spanish - https:/Awww.nia.nih.gov/espanol/caidas-fracturas

CDC - STEADI Older Adult Fall Prevention
https:/Awww.cde.gov/steadi/materials.html

CDC -- A Home Fall Prevention Checklist for Older Adults
https:/Awww.cdc.gov/steadi/odf/check_for_safety_brochure-a.pdf

CDC - Talking about Fall Prevention with Your Patients (Communication steps based

on stages of change for providers)
https:/Awww.cdc.gov/steadi/pdf/Talking_about_Fall_Prevention_with_Your_Patients-

print.pdf

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CDC - Family Caregivers: Protect Your Loved Ones from Falling
https:/Awww.cdc.gov/steadi/pdf/patient/customizable/Caregiver-Brochure-Final-
Customizable-508.pdf

CDC - MyMobility Plan
https:/www.cdce.gov/transportationsafety/older_adult_drivers/mymobility/index.htm|

Family Caregiver Tools

HealthCentric Advisors - Caregiver assessment
https://healthcentricadvisors.org/wp-content/uploads/2019/08/Assessing-Family-
Caregivers.pdf

UHF Next Step in Care -- Make Sure All of Your Family Member's Doctors and the
Home Care Nurse Know All the Over-the-Counter and Herbal Medications Your Family
Member Is Taking
https:/www.nextstepincare.org/uploads/File/NSIC_Medication_Management_4.24.pdf

UHF Next Step in Care - Going Home: What You Need to Know
https:/Awww.nextstepincare.org/Caregiver_Home/Going_Home/

UHF Next Step in Care - Rehab-to-Home Discharge Guide
https:/Awww.nextstepincare.org/uploads/File/Guides/Rehabilitation/Going_Home/
Rehab_to_Home.pdf

UHF Next Step in Care - When Home Care Ends: A Family Caregiver's Guide
https:/Awww.nextstepincare.org/Caregiver_Home/When_Home_Care_Ends/

AARP - Home Alone Alliance: Training and Support for Caregivers
http:/www.aarp.org/ppi/initiatives/nhome-alone-alliance/

AARP - How-To Videos Assist Caregivers Performing Medical Tasks
https:/www.aarp.org/ppi/initiatives/nome-alone-alliance/family-caregiving-videos/

Eric Coleman - Family Caregiver Activation in Transitions (FCAT) Tool (written
permission required before use)

Family Caregiver Alliance - Resources (numerous resources in English, Spanish,
Manaarin, Vietnamese, Tagalog, and Korean on several health topics, caregiving issues,
and strategies, they also host videos and support groups)
https:/Awww.caregiver.org/fact-sheets

Caregiver Action Network - Toolbox (several resources for caregivers including videos

and support team)
https://caregiveraction.org/family-caregiver-toolbox

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UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT

Other

AHA - Watch, Learn and Live videos on cardiovascular conditions, treatments, and
procedures related to hear disease and stroke
https:/Wwatchlearnlive.neart.org/? moduleSelect=welcom

AHA - Monitoring Your Blood Pressure at Home
https:/Awww.heart.org/en/health-topics/high-blood-pressure/
understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home

Quality Improvement Organizations Health Services Advisory Group - Zone Tools for
several chronic diseases in English, Spanish, and Armenian
https:/www.hsag.com/zone-tools/

UHF-commissioned translations of select Zone Tools in Albanian, Italian, Russian, and
Chinese
https://uhfnyc.org/our-work/initiatives/quality-institute/snf-learning-collaborative/
snf-resources/

Improve Post-Discharge Follow-up

HealthCentric Advisors - Post-Discharge Call Script
https://nealthcentricadvisors.org/wp-content/uploads/2019/08/Script-Fol-Phone-Call-
2Day.pdf

HealthCentric Advisors - 2-Day Follow-up Phone Call Documentation
https://healthcentricadvisors.org/wp-content/uploads/2019/08/2dayCall-Followup.pdf

HealthCentric Advisors - 30-Day Follow-up Phone Call Documentation
https://nealthcentricadvisors.org/wp-content/uploads/2019/08/30dayCall-Followup.pdf
UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT

Appendix D: Measures for Assessing
Impact of Interventions

Pre-Discharge Survey General Questions

Were you given educational materials regarding the type of diet that is
recommended for you when you are discharged?

Did you see your physician, and did they speak with you regarding your condition,
medications, and care?

Did nursing staff keep you informed about your plan of care?

Were you given educational information and/or teaching about your diagnosis and
managing at home?

Did you receive any teaching or education from your therapist regarding
equipment that you will be receiving or living with your diagnosis and/or home

safety?

How well did your social worker address your discharge plan with you and your
family?

Do you have any questions or issues you would like to be resolved prior to your
discharge?

% of patients who understood purpose of medications

% of patient who understood how and when to take medications

% of patients who understood possible side effects of some of their medications
% of patients who understood the equipment they will use

% of patients who understood dietary needs

% of patients who understood follow up needs (e.g., Keeping medical
appointment)
UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT

Post-Discharge Follow-up Calls/Survey Questions
General Discharge Education

Were you provided with educational information on your diagnosis, home safety,
and nutrition prior to discharge?

Medication Education

Did you pick up your medications from the pharmacy?

On a scale of 1-10, how would you rate your level of understanding of how and
when to take your medications?

Are you having any problems with your medications? List problems experienced
with medication.

Chronic Disease Education

The ZONE tool was reviewed with the patient

Number of virtual educational sessions conducted

Did the information you receive help prepare you to care for yourself at home?

% of patients who said the information about primary diagnosis was useful

% of patients who said primary diagnosis information was easy to understand

% of patients who said nursing staff explained care needs

% of patients who said the rehab department explained their treatment goals

% of patients who said dietary department educated them on their dietary needs

Follow-Up Care

Do you have a follow-up appointment with physician in the community?
Has the homecare agency been in to see you?

If you have home care services, how quickly did they begin?
Pre-Discharge Video Content Questions

When you first arrived, did someone speak to you about your specific medical and
social needs?

Did the patient watch an educational video via the tablet?

How much did the educational information presented via the tablet help you
better understand your condition?

How much did the information presented via the tablet help you to feel prepared
for your discharge home?

Please tell us what you think about the video(s) you watched by indicating how
much you agree or disagree with each of the statements below.

| enjoyed the educational video.
The video was just the right length to watch.

The video helped me understand how to manage my daily activities given my
condition.

| found the video content to be practical and useful.
The video was easy to follow and understand.
The video has prompted me to consider changing my health care behavior.

The video made learning about health a better experience than | would have
had otherwise.

The staff took my preferences and those of my family into account in deciding
what my health care needs would be when | left the facility.

After watching the video, | feel more confident in caring for my condition.

After watching the video, | clearly understood the purpose of taking each of my
medications.

After watching the video, | had a good understanding of the things | was
responsible for in managing my health.

After watching the video, | feel more confident about symptoms and health
problems to look for when | leave the facility.

UNITED HOSPITAL FUND | HEADING HOME: THE SNF TRANSITION REPORT & TOOLKIT 26