Preparing Clinicians for Transitioning Patients across Care Settings and into the Home through Simulation

Abstract

Assuring home care staff competencies through simulation has the potential to improve care transitions and clinical outcomes. Recreating a home environment can be used for orientation of home care staff and to meet other learning needs. Lessons learned from the use of simulation in a geriatric nursing course in a prelicensure program can be used to prepare clinicians for transitioning patients across care settings. With simulation, learners can identify challenges in patient safety, pain management, and management of patients’ cognitive decline as well as learn how to communication with patients, family members and the healthcare team. Simulation, as an interactive pedagogy, provides opportunities for learners to practice assessment, monitoring, and patient care in a controlled, safe, risk-free environment. Following participation in a simulation, learners are given the opportunity to reflect on ways to improve patient care when transitioning from acute to home care settings. Simulations described in this article can be used for orientation of staff to a home health care agency because they allow clinicians to hone the skills necessary for patient care in the home. Staff educators can also use simulation to validate staff competencies in caring for patients at home.

Home health care (HHC) assists older adults to improve function and well-being, maintain their independence so as to remain at home safely, and avoid hospitalizations and institutionalization (Alliance for Home Health Quality and Innovation, 2014; Westra et al., 2013). Demand for HHC is expected to grow substantially as advances in health care and technology support adults living longer with chronic illnesses. In addition, home is the preferred post-acute setting for patients (Alliance for Home Health Quality and Innovation, 2014).

Many patients who require home care have been recently hospitalized and are highly vulnerable to adverse events during the transition from hospital to home. Care transitions is where the responsibility for a patient’s care shifts from one institution or provider to another or from one level of care to another (McDonald et al., 2014; Naylor et al., 2011; Rydeman et al., 2012). Poor communication between patients and providers, a lack of continuity of care, and changes in medications and treatments place newly discharged patients at risk for hospital readmission (Hung, Truong, Yakir, & Nicosia, in press). Ensuring safe and effective care transitions requires that clinicians assess the needs of patients and families prior to hospital discharge and plan carefully for their follow up care. This detailed planning should involve coordination with care providers across acute and post-acute settings to facilitate the safe transition to the home setting (Labson, 2015a). Simulation provide a strategy for preparing clinicians with the knowledge and skills needed to facilitate hospital-to-home transitions particularly for older adults.

Simulation is an effective teaching strategy that has grown significantly over the past two decades. Simulation allows clinicians the opportunity to develop their clinical knowledge and skills in a safe environment (Gore & Thomson, 2016) and gain an awareness of a clinical situations and context in which care will be provided. To enhance learning outcomes, educators can use a variety of simulation modes including demonstration, role-play, manikin-based simulation, and standardized patients.

In this article we discuss the importance, development, and implementation of two related clinical simulations designed to prepare nursing students for transitioning patients across care settings and gaining the clinical experience needed to conduct a home health visit. While the simulations presented here were designed for nursing students, they also would serve as an approach to prepare newly hired and inexperienced HHC clinicians for care of patients at home. Creating home health care simulation experiences for new hires would allow them to practice with an experienced clinician to enhance skills and time management prior to an actual home visit.

Simulations for Education of Clinicians

The use of simulation-based learning experiences in health care education has grown in recent years. Simulation-based learning includes structured activities for learners to develop knowledge, skills, and attitudes and provides opportunities to respond to realistic clinical situations in a simulated environment (INACSL Standards Committee, 2016). Simulations are often used to facilitate the development of learners’ critical thinking, clinical reasoning, and decision-making skills (Ulrich & Mancini, 2014; Victor, Ruppert, & Ballasy, 2017). Other benefits of using simulations are to (1) decrease learners’ performance anxiety and increase their self-confidence; (2) allow learners to make mistakes in a safe learning environment; (3) promote depth of learning and retention of knowledge through active engagement and immersion in the learning experience; and (4) provide an opportunity for learners to reflect, analyze, and discuss their actions with the goal of improving future practice (Hovancsek, 2007; Oermann, Shellenbarger, & Gaberson, 2018). Along with these benefits, simulation activities are often used to assess the performance of learners and identify further learning needs.

Types of simulations vary in fidelity. The fidelity of a simulation is how realistic the activity is in comparison to clinical practice (Lopreiato et al., 2016). Low-fidelity task trainers, mid-fidelity manikins, and high-fidelity manikins (human patient simulators) can be used to teach psychomotor skills and procedures, concepts of patient safety, therapeutic communication, teamwork, physical assessment, and management of patient care, among other areas. Standardized patients, individuals who have been trained to portray real patients including their emotional, physical, and personality characteristics, are often used to enhance realism in a simulated activity (Lopreiato et al., 2016).

Considering the limited availability of home care and community health experiences for nursing students, nurse educators can develop realistic, interactive, and meaningful simulation activities that prepare students for practice in these settings (Distelhorst & Wyss, 2013). Through simulations, students can gain the knowledge and skills needed to discharge a patient from an acute care setting and understand factors that influence the transition to home. Simulations can provide nursing students, and clinicians new to HHC, with experience in conducting a home health visit and preparing both the patient and caregiver with skills to safely manage new not functional limitations in the home.

Preparing Acute Care Nurses for Transitional Care

The acute care nurse should be aware of The Joint Commission’s (TJC) foundations of safe and effective transitions of care to home and the National Patient Safety goals for home care (TJC, 2013, 2017). These documents provide guidelines and serve as a resource for improving transitions of care across settings and in the home. The acute care nurse should identify risks for readmission, such as frequent hospital admissions, low health literacy, lack of confidence in self-care, and limited knowledge of medical conditions and medications as part of discharge planning (Labson, 2015b). Anticipatory discharge planning is appropriate instead of waiting until the day of discharge. For example, when conducting medication reconciliation in the hospital, the acute care nurse needs to assess if patients understand their medications and how to take them at home, whether they are able to clearly read and open medication containers, if someone needs to assist them with medication administration, and where they store their medications. Documenting the medication list from one facility to another is only the beginning of the process to prevent complications. Ensuring patients understand their medications and other aspects of care can improve adherence and ultimately self-care management (Labson, 2015a). The needs of older adults are often complex, requiring polypharmacy and coordination of multiple services, thus the acute care nurse should plan for complex needs beyond the hospital setting. Houlahan et al. (2017) indicated that this teaching and other interventions in the peri-discharge period were key to preventing hospital readmissions.

For older adults, it is important to complete an assessment of their home environment and risks for readmission (Table 1). Clinicians can assess if there is a need for physical therapy, occupational therapy, nutritional assistance, help with meals and/or grocery shopping, transportation, bathing and dressing, and caregiver relief. If the patient’s family members were providing much of the care prior to hospitalization, the acute care nurse should assess if they can continue to care for the patient and identify resources the caregivers might need such as support groups and respite care.

Table 1.

Transitional Care Needs of Older Adults

Assess Patient’s Needs	Functional Limitations	Assess care support at home to assist with activities of daily living and instrumental activities of daily living. Assess need for home physical and/or occupational therapy referral. Discuss with health care team possible need for home care post discharge.
	Inability to Shop or Cook Meals	Referral to case manager/social worker before discharge to discuss availability of caregiver/family to provide meals for patient and/or meals on wheels.
	Transportation	Assess mode of transportation available to scheduled health care visits.
Medication Management	Medication Reconciliation	Reconcile new and old medications with patient and caregiver responsible for medication administration.
Management of Patient and Family	Health Literacy, Health promotion	Assess health literacy prior to providing health literature and instructions. Provide counseling and support of healthy lifestyles.
Education	Health Care Education to Patient and Family	Provide education on health condition, medications, and plan of care. Provide specific follow-up instructions including whom to call if health is declining. Schedule patient with primary provider prior to discharge.
Transfer of Medical Information	Medical Record	Coordinate the transfer of the patient’s medical record to primary provider.

The acute care nurse can advise the patient and family of available resources within their community. Resources such as the Home Health Agency Checklist (Centers for Medicare & Medicaid Services [CMS], 2017) and Home Health Compare website (CMS, 2017), which are both available on the medicare.gov website, can be shared with patients and caregivers. The acute care nurse can also alert the inpatient case manager of any special needs or considerations the patient may have after discharge.

Simulation 1 to Prepare Students for Transitional Care: Hospital to Home

In a geriatric nursing course in a prelicensure program, students participated in a high-fidelity simulation of a postoperative older adult female patient who sustained a right femoral neck fracture as a result of a fall at home. This simulation was designed to prepare students for discharging this patient to the home setting and identifying factors that could impede an effective transition of care. Objectives of the case included addressing safety, pain management, and the patient’s cognitive decline while on a patient-controlled analgesia (PCA) regimen. Students were expected to demonstrate ability to obtain a patient history and complete a focused physical examination. Objectives of the simulation-based learning experience also included communicating with the patient, family members, and health care providers. Students were challenged to assume the role of patient advocate when it is discovered during the scripted simulation that the patient’s daughter, played by another nursing student, is pushing the PCA button.

Immediately following the simulation, the debriefing session allowed for reflection of the experience. Students were given the opportunity to explore pain management using a PCA and to identify the importance of only the patient controlling the PCA. Discussion directed by the simulation facilitator guided students in examining how this situation was best handled. During the debriefing, students were able to make a connection to a clinical situation they might face in their own clinical practice in the future. The debriefing also allowed students to discuss the transition of this patient’s care to the home setting.

After using this simulation with students, we explored how it could be expanded to address home care for this postoperative elderly patient. Questions included if the patient had adequate housing, access to medical care, and a support system. With the need to prepare students for transitional care and anticipate the patient’s needs in the home, the case was expanded to a HHC simulation for this patient.

Preparing Home Health Care Clinicians

The home health care clinician needs to be aware of risks for readmission and to be proactive to mitigate them. The initial intake assessment of the home environment should take into account the patient’s functional status, physical abilities, cognitive deficits, psychosocial support, and social needs. A thorough assessment should identify whether the patient may benefit from meals on wheels, a hospital bed, a wheelchair, oxygen, physical therapy, occupational therapy, speech therapy, palliative care, caregiver support, respite care, and transportation services, among other resources.

The HHC clinician coordinates the multidisciplinary community resources available for patients, advocating for use of available resources and communicating with providers to access those resources. Safe transitions from acute to home care and back to acute care if needed require multidisciplinary communication that is clear and consistent. Communication across settings and providers should include any recent changes in the patient’s medications, functional status, physical abilities, and cognition, and the patient’s needs for psychosocial and other types of support.

Simulation 2 to Prepare Students for Home Health Visit

Community-based simulations create a safe place for students to conduct an initial home visit to assess needs of patients, adherence to medications, nutritional status, support systems, and home safety. To prepare students for conducting a home health visit, we developed a case scenario of an older adult male, played by a standardized patient, with a history of dementia. The patient lives at home with his wife who is currently hospitalized for repair of hip fracture. Their 45-year old daughter has traveled across the country to check on both parents after hearing about the fall her mother sustained. The daughter is staying in the hospital with her mother and is not checking in with her father on a regular basis but remains available by telephone.

Our simulation laboratory does not have a dedicated apartment area, but with some creativity, the simulation staff designed a simulated home with a living room and kitchen area (Supplemental Figure 1). The simulated home setting was easily recreated with available furniture and some common household items used for props, which are saved in a bin from session to session. These props include scatter rugs, photo frames with pictures of the family members and pets, empty bottles of wine and beer, fast food wrappings, and an array of medications in a plastic shopping bag (Supplemental Figures 2 and 3). It is important for educators to think of environmental hazards that older adults may be exposed to in a home setting to have the necessary props for setting the scene.

The simulation objectives include assessing the home for safety, vital signs, medication reconciliation, mobility and fall risk. Students perform a mobility test and also need to attach the urinary drainage bag to the patient’s leg. In addition, all students are asked to identify resources in the community (e.g., meals on wheels, adult day services) that might be appropriate for referral. Students are placed into groups of typically 8 to 9 students each. Prior to going into the apartment, they organize themselves in preparing for and conducting the assessments. Generally, students get into pairs with each pair taking responsibility for conducting one of the areas of assessments.

Students enter the apartment and after introducing themselves to the elderly man, begin their assessment of the patient and home environment. At this point the facilitator evaluates if the students introduced themselves to the patient and described their role in conducting the home visit. The patient is alert and oriented to person (knows who he is) and place (knows he is at home). However, he is not oriented to time or situation, cannot remember that his wife fell at home several days ago and is in the hospital recovering from surgery, and cannot recall if he took his morning medications.

The home is cluttered and has many environmental hazards including scatter rugs, medication bottles in various places in the home, uneaten food, dirty dishes, (Figures 1–3). The patient, played by a standardized patient, is sitting on a chair in the living room, with the urinary drainage bag not attached properly to his leg. This role also can be played by a student or clinician with a simple script that addresses the case objectives. The patient tells the home care clinician (played by a nursing student) that his wife keeps the house organized, oversees his medication regimen, and does the cooking and cleaning. Students are expected to secure the urinary drainage bag to the patient’s leg. Another objective of this home care simulation is for students to measure mobility in patients who are able to walk on their own. Students use the Timed Up and Go test to measure this (Lusardi et al., 2017; Podsiadlo & Richardson, 1991).

Figure 1.

Figure 3.

Students document areas of concern in the home setting and suggest possible interventions and how these interventions can be evaluated (Table 2). The simulation facilitator observes the experience and makes notes of students’ actions, which are then discussed in the debriefing.

Table 2.

Senior Apartment Simulation

Debriefing the Simulation

Debriefing is a critical conversation that follows a simulation event (Cantrell, 2008; Dreifuerst, 2012, 2015). Educators are challenged to conduct meaningful debriefing sessions that allow learners to review their actions and decisions in the simulation activity. Building purposeful time into this final phase of the simulation allows for reflection and discovery, arguably the time when most of the leaning occurs. Retention of information discussed is greatly enhanced with consistent use of debriefing (Eppich & Cheng, 2015).

In the home setting, patient-centered care requires staff to be aware of the needs of patients and family members. A way to enhance staff’s awareness of the patient’s situation is to engage in debriefing as an active learning opportunity. In the debriefing learners can share their perceptions of the patient and explore their feelings interacting with the patient in the home setting. Significant learning occurs when students reflect on the home health simulation and discuss ways to improve patient care when transitioning from acute to home care settings. Experiential learning through this simulation with reflective and facilitative debriefing enables the students to transfer the acquired knowledge into clinical practice. Students reflect on the patient assessment in the home, medication reconciliation challenges, and risks of an unsafe home environment.

During the debriefing, students also learn that all clinicians should be aware of appropriate community-based resources for patients, regardless of the setting. Lastly, the debriefing session reviews the importance of multidisciplinary communication after a home health assessment by discussing how clinicians can advocate for safe transitions through clear and consistent communication. Factors that impact safety in the home can be summarized during the debriefing as well as discussion of resources for the caregiver to keep the home safe. Home health care varies greatly from the acute care setting, thus a home-based simulation with debriefing challenges students to anticipate patient needs in the home and provides experience in conducting a home visit.

Conclusions

Recreating a home environment can go beyond the academic setting and be used for orientation for home care staff and to meet other learning needs of clinicians. Our simulation was created easily with available furniture and using common household items for props. While our simulations were developed for prelicensure nursing students, they can easily be adapted for education of staff in home care agencies. Specifically, our simulations incorporated care of older adults and transitional care, and exposed students to care of patients in a home setting. Students were able to adapt their clinical and critical thinking skills learned in the skills laboratory to the home, e.g., completing vital signs, attaching the urinary drainage bag to the patient’s leg, and accessing community resources to support a patient in the home environment. Simulations such as the ones we described in this article can be used during orientation of staff to a home health care agency because they allow new and experienced clinicians to develop the skills necessary for patient care in the home. Further, with the increasing acuity of home care patients across the lifespan, staff educators can use simulations to validate staff competencies in high technology skills such as care of patients in the home with ventilators and central lines (Center, Faragher, Bittner, & Cheuvront, 2014). Assuring home care staff competencies through simulation based orientation has the potential to improve care transitions and clinical outcomes.

Supplementary Material

SDC 1

Supplemental Digital Content, Photograph 1, living room

SDC 2

Supplemental Digital Content, Photographs 2 and 3, props

Figure 2.

Suggested callouts.

Care transitions is where the responsibility for a patient’s care shifts from one institution or provider to another or from one level of care to another.

Simulation-based learning includes structured activities for learners to develop knowledge, skills, and attitudes and provides opportunities to respond to realistic clinical situations in a simulated environment.

The needs of older adults are often complex, requiring polypharmacy and coordination of multiple services, thus the acute care nurse should plan for complex needs beyond the hospital setting.