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.

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.

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.

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.

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 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

This chapter will review the common causes of dementia and their typical presentations in the NF. Nursing staff will learn about the characteristics of residents with dementia that place them at high risk for hospitalization. The focus will be on reducing barriers to quality transitions of care for residents with dementia, which include poor communication or incomplete transfer documents.

This chapter will discuss essential quality care for residents with dementia, with a focus on assessment, behavior management, medication safety, symptom management, and regular assessment of decision-making capacity. Specific roles of interdisciplinary team members will be examined to keep the resident at the highest level of function.

This chapter is a question and answer discussion with a skilled nursing facility leader, Dr. Elizabeth Galik.

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.

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.

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.

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 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 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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.