Nursing's Role in Successful Transitions Across Settings.

Care transitions across settings (hospital, other institutional settings, and home) are vulnerable exchange points for patients and family caregivers that contribute to higher risk of poor health outcomes. The Institute of Medicine and National Quality Forum identified improving transitions across the continuum from acute care to home as a national priority. Despite this, care transitions for individuals with disabling conditions, such as stroke, remain inefficient, resulting in unmet patient and caregiver needs, increased safety risks, high rates of preventable readmissions, and increased healthcare costs. Nurses have an integral role in care coordination activities at various practice levels and settings, thus nurses can help transform healthcare delivery for stroke survivors through improving transitions. Stroke is the leading cause of major disability. Annually, ≈800 000 people are hospitalized for stroke in the United States. In 2010, there were ≈6.6 million stroke survivors with a predicted increase in prevalence of >20% over the next 20 years. Despite medical advances resulting in reduced stroke mortality, disability after stroke remains a major concern and adds complexity to care transitions for this population. Given stroke prevalence, improving nurses’ engagement in optimizing care transitions for this population is essential. Readmissions after discharge from institutional settings to the community are a closely monitored measurement of care transition effectiveness. Readmissions may indicate unresolved problems, discharge to an inappropriate level of care, quality of immediate posthospital care, or a combination of these factors. Thirty-day readmission rates after hospital discharge are reported at 14.4%, with 11.9% of these determined as preventable. Readmissions after discharge from inpatient rehabilitation facilities range from 9.0% to 16.7%, varying with the severity of stroke impairment. Patients discharged to skilled nursing facilities have the highest 30-day readmission rates. Readmissions are associated with substantial economic burden on the healthcare delivery system. The impact of stroke on function and activities of daily living varies widely. The need for continued medical and nursing care management is based on patient need. Approximately 60% of stroke patients require postacute care (PAC) services after acute inpatient discharge. PAC includes inpatient rehabilitation facilities, skilled nursing facilities, and community-based services, including outpatient and home health. Determining the appropriate level of PAC on hospital discharge is a key component in ensuring optimal outcomes for stroke survivors. Nurses contribute to this determination through a biopsychosocial and ecological assessment of the patient and family caregiver. Factors that must be considered include the individual’s medical needs, prestroke level of function, rehabilitation tolerance, and community supports. The family caregiver’s capacity to care for the stroke survivor including preexisting health conditions, other responsibilities, previous caregiver experiences, and available social support must also be considered. Other important considerations include family dynamics, financial resources, and the community living setting. Systems factors include the components of care and services, intensity of services (eg, number of hours of nursing care or therapy), and structure of available programs. Nurses interact with patients/families at their most vulnerable times and often learn information critical to successful transition planning. They play a key role in promoting successful transitions by developing and evaluating the transition plan and identifying and communicating barriers to the plan. Examples of barriers include limited finances to cover out-ofpocket costs of PAC and family members who do not have the capacity to provide care post discharge. Communicating this information to the interprofessional team early in the patient’s hospital stay is essential to assure that the transition plan is tailored to the needs of the patient and family, and that patients are transferred to the appropriate PAC setting. The intensity of medical, nursing, therapy, and other services varies significantly along the care continuum from inpatient rehabilitation facilities to skilled nursing facilities to community-based care. To be most efficient and effective, care settings must be matched to patients’ needs to ensure optimal function and participation in meaningful activities and avoid costly readmissions. Comprehensive rehabilitation with adequate resources, dose, and duration must be provided to achieve these outcomes. Providers can use the Determination of Probable Discharge to the Community Model (Figure) to identify important elements to ensure that the needs of patients with stroke can be met in the identified Nursing’s Role in Successful Transitions Across Settings