Table 1.

Recommendations for Research to Improve Transitional Care for Nursing HomeRehabilitation Patients

AGSHCSC Position Statement on Transitional Care3	Research Roadblock in the NH Rehabilitation Setting	Recommendations for Health Care System-Based Research	Recommendations for Family-based Research
1. Involve patient and caregivers in decisions and prepare them for the next setting.	Difficulty in convening meetings between families and NH staff to discuss clinical status and treatment options and to prepare for care in the next setting.	Recruit families earlier in the care transition chain. Consider telephone conference, email or other alternative means of communication. When possible, create internal staff-based initiatives that prioritize family meetings.	Train family to better utilize existing opportunities to communicate with staff and empower them to initiate communication when needed for proper patient care.
2. Insure good bidirectional communication between clinicians at the sending and receiving ends of care.	Discharge summaries may not be communicated to the next site of care and may omit critical information such as mental health issues that require follow- up.	Create a discharge summary supplement that addresses mental health issues such as depression. Recruit prospectively at PCP offices to help ensure that patients can accurately identify their PCP. Include a process for ensuring that discharge summaries are communicated to the PCP as part of the research protocol and intervention. Explore alternative communication methods such as electronic medical record sharing and electronic ‘smart cards.’	Help families create and maintain a personal patient medical record that includes facility discharge summaries and is tailored to the specific health and mental health needs of the patient.
3. Develop policies that promote high quality transitional care, including changes to reimbursement rules.	Poor response from PCPs; also, patients are often unable to identify their PCP, or they indicate that they do not have one.	Recruit patients prospectively through PCP practices to ensure that patients and research staff can identify PCPs and that PCPs are involved in the research study. Identify and work with the hospitals that discharge patients for rehabilitation care to targeted NHs to promote earlier patient identification.	Teach patients and their families to communicate better with the patient's PCP.
4. Provide education to all professionals involved in transferring patients across settings.	Staff time constraints restrict opportunities for staff training and staff-based care manager approaches.	Utilize existing NPs as case managers.	Focus on educating patients and families to work with care providers.
5. Conduct research to improve transitional care processes, with a focus on patient and family involvement and training healthcare professionals.	Patient frailty, pain, therapy schedules and short stays severely impact recruitment, data collection, and intervention protocol schedules. Poor quality admission information makes eligibility determination slow and costly.	Start earlier in the transition chain, including recruiting prospectively at the PCP practice or hospital. Current NH trends to utilize electronic record systems using ICD-9 codes may simplify eligibility determinations.	Sensitize patients and families to the challenges in transitional care and to their role in promoting research to improve care.

Note: Primary Care Physician (PCP); Nursing Home (NH)