The majority of patients who returned home after staying in a skilled nursing facility for a short-term stay said there were “substantial gaps” in their care, according to a survey conducted by the United Hospital Fund (UHF).
Of 263 patients surveyed across eight New York nursing homes, rehabilitation centers and other skilled nursing facilities, 80% said they received and understood discharge instructions, yet still experienced gaps in preparation and care coordination — often leading to worse outcomes for frail residents, the report said.
UHF surveyed 249 caregivers for the report as well last year — partnering with the eight facilities in a two-year learning collaborative with support from the Mother Cabrini Health Foundation.
Between August and December 2020, patients and caregivers were instructed to identify “pain points” after discharge back to the home within the past six months. Responses were broken down into four aspects of a short-term stay: transition planning, medication education, experience after discharge and information about COVID-19.
Shortfalls were shared with the skilled nursing facilities, who will use the feedback to improve the discharge process, UHF said. The non-profit organization will file a subsequent report to see how the facilities improved.
“Our survey results add to the evidence that transitions of care continue to demand far greater attention,” the report concluded. “We appreciate [participating SNF] commitment to this project, especially during this very challenging time of the COVID-19 pandemic.”
Only 50% of Medicare Part A patients returned to their home or community after their short stay in a nursing home, according to the Centers for Medicare & Medicaid Services (CMS) The statistic was included in UHF’s report.
The report indicates nursing homes are carrying out important parts of discharge planning effectively, with 70% receiving medications, equipment and added help after discharge and 75% reporting on-time home care services.
Performance fell short in other areas, the report said, including understanding medications and their side effects, and being asked about social needs like food, housing, transportation and affordable care.
“Even when asked, close to half of those in need were not referred to services to help mitigate those concerns,” UHF said in its press release announcing the report. More than 40% said they didn’t receive a follow-up call after discharge.
Caregiver stress specifically is “well documented,” the report said. Facility staff can alleviate that stress by making sure caregivers are well prepared once discharge comes, instead of explaining everything during a “rush of activity” at the end of a stay.
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