Table 1.

Connect-Home: Transitional Care in Skilled Nursing Facilities

Transitional Care in 4 Steps
Step 1	Complete a Transition Plan of Care (TPOC) by day 15–17 (of 20 day stay) Use the TPOC to organize rehabilitation, medical follow-up, caregiver supports, medication instructions, and other self-care activities at home.
Step 2	Convene a care plan meeting by day 8–10 (of 20 day stay) Set priorities, review the TPOC, and educate the patient and primary caregiver.
Step 3	Implement the transition plan by day 17 (of 20 day stay) Teach the patient and caregiver the TPOC Reconcile the final medication orders and the patient’s discharge medication list Schedule follow-up appointments On the day of discharge Teach the patient and caregiver the written TPOC Fax medical records to the community provider.
Step 4	Call the patient or caregiver at home within 72 hours of discharge Review the TPOC, triage medical questions, and confirm home and primary care activities.
Tools, Training and Technical Assistance to Implement Connect-Home
Tools	Tools on paper and in the electronic medical record to create a TPOC and home medication list
Training	4 hours of face to face training with nurses, rehabilitation therapists, social workers, and others; training includes transitional care roles and responsibilities and details the 4-step process
Audit	Interviews with SNF staff and patient chart audits to assess adherence to study procedures.
Feedback	In person dialogue with individual staff to discuss performance and identify strategies for refining implementation.