You are now viewing our public site. Back to Dashboard

Effective Transitions of Care for High-Risk Residents

Learn transitions of care best practices to improve quality and decrease readmissions for complex, high-risk residents.

Subscribe Now Already a subscriber? Sign in to start.

About this Certificate Program

Transitions of care have a significant effect on the quality of life of residents as well as the reputation and value of the care provided by the nursing facility. The fundamental goal of nursing care during transitions is to promote safe and person-centered care that will achieve resident and family caregiver goals. This certificate will provide essential knowledge of best practices during transitions, with a focus on communication, safety, patient education, and accountability. The certificate first focuses on basic knowledge of transitions of care and progresses to essentials of nursing care required for those at highest risk for potentially avoidable hospitalizations including cognitive impairment, heart failure, diabetes, acute myocardial infarction, and residents with multiple chronic conditions.

Target Audience

Nurses in all levels of care within long-term care including staff nurses, MDS coordinators, supervisors, and directors of nursing. Nurses in case management, care coordination and those who work in post-acute care settings including skilled nursing facilities, home care agencies, and acute rehabilitation will greatly benefit from this content.

Goals & Objectives

  • Review evidence-based models of nursing care during transitions of care.
  • Examine the types of avoidable, preventable, or unnecessary hospitalizations of high-risk residents.
  • Evaluate and communicate essential clinical data during transitions of care for residents.
  • Identify methods to improve collaboration and continuity of care between residents/families, providers, and other healthcare facilities.
  • Recognize the influences in your facility that affect hospitalization and readmission rates.

What's Included in the Certificate Program

Courses
Accredited Online Courses*

15 hours of online video lectures and patient demonstrations.

Courses
Case Study Interviews

Recorded Q&A sessions between instructors and practice managers.

Courses
Interactive Learning Assessments

Case-based quizzes to evaluate and improve clinical reasoning.

Section 1: Introduction to Transitions of Care in Skilled Nursing Facilities

2 Chapters

Transitions of Care: Reduce Hospitalizations in SNFs Part 1keyboard_arrow_down

Course
  • Introduction to Transitions of Care For SNF ResidentsChapter 1

    This chapter will define transitions of care and their effect on residents at the time of admission to the SNF and subsequent transitions, including discharge to home. Barriers to effective transitions and statistics that characterize the complex and challenging aspects of transitions of care in the SNF will be reviewed. Common high-risk characteristics of SNF residents that make them susceptible to poor outcomes will be discussed.

  • Resident and Family Engagement for Safe Transfers of SNF ResidentsChapter 2

    This chapter will discuss the need for person-centered care, communication and safety during transitions of care. The focus of the chapter will be on transition planning, essential information that supports quality transfers, and the requirements for education and engagement of the resident and family during transitions. The role of the enhanced interprofessional team in the transitions of care process will be evaluated. Participants will have an increased awareness of the need for ongoing assessment, communication, education, and documentation for high-risk residents.

  • Healthcare Provider Engagement For Safe Transfers Of SNF ResidentsChapter 3

    This chapter begins with a discussion of safe medication reconciliation. Additional focus is on essential follow-up care and the roles of each health-care provider in quality transitions of care. Requirements for enhanced communication between sites of care and roles of accountable clinicians is emphasized. Evidence-based models of transitions of care are included. The goals of patients and families will be highlighted as part of the plan of care.

  • A Case Study Of The Typical High-Risk ResidentChapter 4

    This chapter presents a case study of a typical high risk resident admitted to the SNF. The focus will be on comprehensive person-centered care, communication and safety. The case will synthesize the Part I discussion of evidence based transitions of care.

  • View full course details »

Transitions of Care: Reduce Hospitalizations in SNFs Part 2keyboard_arrow_down

Course
  • Hospitalization of SNF Residents and Changes in ReimbursementChapter 1

    This chapter examines the types of avoidable, preventable, or unnecessary hospital admissions from the SNF. An overview of evolving Medicare financial and reporting changes related to transitions of care is included. Participants will have a greater understanding of accountability for members of the interdisciplinary team in prevention of poor outcomes.

  • Quality Improvement (QI) Tools to Improve Transitions of SNF ResidentsChapter 2

    Quality Improvement tools and strategies are available to assist SNF staff in early identification, assessment, communication, and documentation of changes in resident status. There is a focus on tools to identify early changes in resident status. This chapter will support the facility’s use of recommended QI tools to improve quality of high-risk resident care and to reduce hospitalization rates.

  • Expand and Improve Transitions of Care Programs in the SNFChapter 3

    This chapter will review the steps involved in transitions of care for SNF residents. Available evidence will be included to support quality care for each phase of the transition process. Recommendations to improve policies and procedures in the SNF will assist facilities to enhance their reputation in the community and prevent unnecessary transitions of care.

  • Panel Discussion With SNF LeadersChapter 4

    This chapter will include a panel of SNF leaders and staff to discuss their unique experiences with transitions of care. The panel will provide an opportunity to hear additional problems, concerns, and solutions to issues related to transitions of care for SNF residents.

  • View full course details »

Section 2: High-Risk Patients: Cardiopulmonary

4 Chapters

Transitions of Care: Heart Failure Part 1keyboard_arrow_down

Course
  • Definition, Pathophysiology, and Common Causes of HFChapter 1

    This chapter will review the pathophysiology of HF as a syndrome. Nursing staff will be taught the significance of high-risk characteristics of the HF resident and evaluate the effects of other comorbidities on HF. Clinical data essential for safe transition of the HF resident from acute care will be included in this chapter.

  • Comprehensive Assessment and Management of Residents With HFChapter 2

    Signs and symptoms can change rapidly, and nursing staff must use critical thinking to safely manage residents with HF in the SNF. Common signs and symptoms of HF that place SNF residents at elevated risk for rehospitalization will be discussed in this chapter. An overview of evidence-based management of residents will include diagnostics, medications, and treatments. Physical examination skills will be reviewed. Specific roles of interdisciplinary team members in evidence-based HF management will be examined.

  • Case Study Part 1Chapter 3

    Part 1 of the case study will summarize and synthesize the learning acquired in the first course on nursing care for high-risk residents with HF. Interactive technology will allow the learner to use his/her knowledge and skills to achieve the desired outcomes for a complex resident with HF.

  • View full course details »

Transitions of Care: Heart Failure Part 2keyboard_arrow_down

Course
  • Education for Self-Care Management of HF ResidentsChapter 1

    This chapter will focus on the role of the nursing staff and other members of the interdisciplinary team to enable residents and/or their caregivers to manage self-care when they return home. Education needs to be provided with consideration of functional deficits, other chronic diseases, possible cognitive changes, and health literacy. Education will include content related to diet, activity, medications, and signs and symptoms that suggest worsening of chronic disease.

  • Discharge Planning for HF ResidentsChapter 2

    This course will include essential discharge planning to enable the resident and/or their caregivers to safely manage their care at home. Content will highlight nursing’s role in coordination of care with the interprofessional team and validation that all referrals are in place at the time of discharge. Additional content will focus on the essential clinical data to be shared with follow-up providers at the time of transition from the SNF.

  • Case Study Part 2Chapter 3

    Part 2 of this case study will summarize and synthesize the learning acquired in the second course on nursing care for high-risk residents with HF. Interactive technology will allow the learner to use their knowledge and skills to achieve the desired outcomes for a complex resident with HF.

  • View full course details »

Transitions of Care: Pulmonary Disease Part 1keyboard_arrow_down

Course
  • Pathophysiology and Common Causes of COPD and PneumoniaChapter 1

    This chapter will review the pathophysiology of COPD and pneumonia. Nursing staff will learn about the significance of high-risk characteristics of the resident with COPD or pneumonia with other comorbidities. Clinical data essential for safe transition of the resident with pulmonary disease from acute care will be included in this chapter.

  • Comprehensive Assessment and Management of Residents With COPD or PneumoniaChapter 2

    Sudden worsening of pulmonary symptoms can occur, and nursing staff must use critical thinking to safely manage residents with COPD or pneumonia in the SNF. Common signs and symptoms of COPD or pneumonia that place SNF residents at very high risk for rehospitalization will be discussed in this chapter, with a review of required physical examination skills. An overview of evidence-based management of residents will include diagnostics, medications, and treatments. Specific roles of interdisciplinary team members in evidence-based management of COPD and pneumonia will be examined.

  • Demonstration: Pulmonary AssessmentChapter 3

    This chapter is a demonstration of a pulmonary assessment led by Cathy Wollman.

  • View full course details »

Transitions of Care: Pulmonary Disease Part 2keyboard_arrow_down

Course
  • Education for Self-Care Management of Residents With COPD or PneumoniaChapter 1

    This chapter will focus on the role of the nursing staff and other members of the interdisciplinary team to enable residents and/or their caregivers to manage self-care when they return home. Education will include content related to diet, activity, medications, use of inhalers, and signs and symptoms that suggest worsening of the resident’s pulmonary disease.

  • Discharge Planning for Residents With COPD or PneumoniaChapter 2

    This chapter will focus on the essential clinical data to be shared with follow-up providers at the time of transition from the SNF. Appropriate referrals for residents with pulmonary disease will be discussed. This chapter will also focus on individual resident and caregiver goals based on prognosis and their potential for rehabilitation. The importance of advance care planning, hospice, and palliative care will be included.

  • Interactive Case StudyChapter 3

    The case study will summarize and synthesize the learning related to the high-risk resident with COPD or pneumonia in the SNF. Interactive technology will allow the learner to use his/her knowledge and skills to provide quality care and achieve the desired outcomes for a complex resident with COPD or pneumonia.

  • View full course details »

Section 3: High-Risk Patients: Dementia, Cardiac, Diabetes, Fluid Balance

5 Chapters

Transitions of Care: Dementia Part 1keyboard_arrow_down

Course

Transitions of Care: Dementia Part 2keyboard_arrow_down

Course
  • Education and Discharge Planning for the Resident With Dementia or Cognitive ImpairmentChapter 1

    This chapter will focus on the role of the nursing staff and other members of the interdisciplinary team to enable residents and/or their caregivers to manage care if they return home. Additional focus will be on appropriate interventions to prevent acute care hospitalizations since those events are often overwhelming for residents and can result in delirium, compromised function, longer-than-average hospital stays, and poor post-discharge outcomes.

  • Individual Resident and Caregiver Goals Related to Prognosis and Potential for RehabilitationChapter 2

    This chapter will focus on individual resident and/or caregiver goals based on the resident's prognosis and potential for rehabilitation. The importance of advance care planning, hospice, and palliative care will be included, with a discussion of guidelines for hospice qualification.

  • Interactive Case StudyChapter 3

    The case study will summarize and synthesize the learning related to the high-risk resident with dementia in the NF. Interactive technology will allow the learner to use his/her knowledge and skills to provide quality care and prevent unnecessary hospitalization for a complex resident with dementia.

  • View full course details »

Transitions of Care: Acute Myocardial Infarction (AMI)keyboard_arrow_down

Course
  • Background Information: Anatomy and Physiology and Signs and SymptomsChapter 1

    Early identification of potential problems in high-risk residents can prevent complications and readmissions. This chapter will focus on the normal aging process of the cardiovascular system, along with defining anatomy and physiology of an AMI. Typical and atypical signs and symptoms and risk factors of AMI will be identified.

  • Assessment and TreatmentChapter 2

    Assessment and identification of high-risk residents and evidence-based treatment guidelines to reduce complications for high-risk residents post AMI will be discussed in this chapter.

  • Lifestyle ConsiderationsChapter 3

    Lifestyle modifications have been strongly linked to reduction in recurrent AMI and further progression of cardiovascular disease. This chapter will focus on lifestyle considerations for the SNF resident post AMI.

  • Improvement of Care Transitions, Discharge Plans, and CommunicationChapter 4

    Improved communication, follow-up and medication reconciliation are needed to provide safe transitions between levels of care. This chapter will discuss strategies to improve care transitions and adherence to the resident’s discharge plan, along with some general reasons why residents may be readmitted.

  • Case StudyChapter 5

    In this case study, the learner will be able to synthesize what was learned in the prior chapters in this course. Interactive technology will allow the learner to use their new knowledge and skills to meet the learning objectives by assessing and developing a plan to prevent readmission of a high-risk resident with AMI.

  • View full course details »

Transitions of Care: Diabeteskeyboard_arrow_down

Course
  • Pathophysiology and SymptomsChapter 1

    Diabetes is a complex problem involving many body systems. Knowledge of diabetes pathophysiology is important in the understanding of its manifestations. This chapter will discuss overall pathophysiology of diabetes, distinguish type 1 from type 2, and identify signs and symptoms of the disease.

  • Diabetes ManagementChapter 2

    Management of diabetes requires a multifaceted approach. This chapter will focus on nutrition, activity, medications, and monitoring to promote better outcomes.

  • Assessing for ComplicationsChapter 3

    Prevention and early recognition of developing complications is essential for improving resident outcomes. This chapter provides an overview of assessment parameters for early recognition of impending complications to prevent readmissions, with a focus on hypoglycemia, hyperglycemia, urosepsis, and wounds. Suggestions of interventions that can be used to prevent and address common diabetic complications will be given.

  • Case StudyChapter 4

    In this case study, the learner will be able to synthesize what was learned in the course. Interactive technology will allow learners to use their new knowledge and skills to reduce rehospitalization for high-risk patients with diabetes.

  • View full course details »

Transitions of Care: Hydration & Fluid Balancekeyboard_arrow_down

Course
  • Background: Hydration StatusChapter 1

    Elderly SNF residents are at high risk for dehydration and infections due to fragility and comorbid conditions. This chapter will focus on physiological changes of aging in relation to hydration status and debility that can put the elder at risk for developing dehydration and infections. Signs and symptoms of dehydration and assessment parameters will be identified; the genitourinary system will also be discussed. Strategies to promote normal hydration status will be promoted.

  • Urinary Tract Infection (UTI)Chapter 2

    The urinary tract is a common site of infection that can lead to acute morbidity and long-term complications. This chapter will discuss pathophysiology, risk factors, prevention strategies, and signs and symptoms of a UTI. Assessing a resident’s hydration status and recognizing a developing UTI will be reviewed to prevent readmissions.

  • SepticemiaChapter 3

    Septicemia is a serious condition that is often associated with a high rate of mortality. Costs of treating septicemia are great, and septicemia has been touted as an illness that causes the most readmissions of Medicare recipients. This chapter will discuss the pathophysiology, risk factors, prevention strategies, treatment options, and signs and symptoms of septicemia. Nursing strategies to identify and recognize septicemia to prevent hospital readmission will be developed.

  • Case StudyChapter 4

    In this case study, the learner will be able to synthesize what was learned in prior chapters of this course. Interactive technology will allow the learner to use their new knowledge and skills to meet the learning objectives to prevent readmission of high-risk residents.

  • View full course details »
Instructors
Cathy Wollman

DNP, RN, GNP-BC, CRNP

Constance Sheets

DNP, RN, GCNS-BC

Rose Flinchum

MSEd, MS, RN, ACNS-BC, BC-ADM, CDE

CEU Approved

15 total hours* of accredited coursework.
MedBridge accredits each course individually so you can earn CEUs as you progress.

      Our clinic could not be happier with MedBridge.

Amy Lee, MPT, OCS
Physical Therapy Central

       MedBridge has allowed us to create a culture of learning that we were previously unable to attain with traditional coursework.

Zach Steele, PT, DPT, OCS
Outpatient Physical Therapy & Rehabilitation Services

    MedBridge has created a cost-effective and quality platform that is the future of online education.

Grant R. Koster, PT, ATC, FACHE
Vice President of Clinical Operations, Athletico Physical Therapy

Frequently Asked Questions

Do I get CEU credit?
Each course is individually accredited. Please check each course for your state and discipline. You can receive CEU credit after each course is completed.

When do I get my certificate?
You will receive accredited certificates of completion for each course as you complete them. Once you have completed the entire Certificate Program you will receive your certificate for the program.

*Accreditation Hours
Each course is individually accredited and exact hours will vary by state and discipline. Check each course for specific accreditation for your license.

Do I have to complete the courses in order?
It is not required that you complete the courses in order. Each Certificate Program's content is built to be completed sequentially but it is not forced to be completed this way.

How long do I have access to the Certificate Program?
You will have access to this Certificate Program for as long as you are a subscriber. Your initial subscription will last for one year from the date you purchase.

Sample Certificate

Sample Certificate

Complete this series to receive your certificate.

Subscribe Now

Certificate Program
Earn an official certificate of completion from MedBridge.
  • Show the world your achievement
  • Share your course record with peers and employers
  • Show patient and clients your commitment to education

Sign up to get free evidence-based articles, exclusive discounts, and insights from industry-leaders.