With many of the upcoming nursing home survey changes being tied to care transitions to home, hospitals or other settings, operators say the link between clinical teams and these transitions is more important than ever. However, even though worker shortages have complicated transitions, operators haven’t given up on finding workarounds.

So, how do operators square the circle, and make sure they’ve got the staff they need and skills to remain compliant when it’s an uphill battle to find staff?

For Lisa Chubb, chief clinical officer at Brickyard Healthcare, reliance on existing tools and processes is a crucial stopgap, along with use of technology platforms.

Using electronic health records to print out patient-specific medication lists and discharge instructions, and adding in more notes or getting such paperwork in a different language is a huge plus during care transitions, she said.

Indiana-based Brickyard also has a library of patient education around medications, diagnosis and instructions.

“It even helps set the expectations for what to expect when you go home with home health or other providers, what that looks like,” Chubb said of Brickyard’s resident library. “It’s in a multitude of languages.”

Translation services for staff to use is another unsung hero for care transitions, said Michelle Stuercke, chief clinical officer with Transitional Care Management.

“You’re not going to run into problems on a Tuesday at 2 p.m., but Saturday at 4 a.m.,” said Stuercke. “What tools does your staff have to be able to communicate with that resident, or provide them the information they need to make sure that they’re aware of where those tools are, and what tools they can use.”

Communication across care settings

Building care teams across care settings, with strong communication and knowledge of processes, is key to handling discharges and admissions properly while avoiding survey tags.

For one, health literacy is peppered across regulations and in the Minimum Data Set (MDS), which makes it imperative that family members and nurses – from one care setting to another – are communicating frequently to make sure medication management is correct, and instructions for care are given in a way that everyone understands.

Stuercke said she saw the value of care team communication when a family member’s discharge paperwork had incorrect instructions for double the medication the doctor had prescribed when transitioning to home and community-based care.

“She’s 80 years old. Many, many patients are rule followers, and if doctors tell them to do it, they’re going to do exactly what they say,” said Stuercke.

Safe discharge instructions and communication between nursing home doctors and HCBS nurses could make a difference in avoiding a high scope and severity tag.

“Make sure that everything that we give to individuals is in a language, written in a way they understand, or that their caregivers understand,” said Stuercke. “If the caregiver speaks Spanish, we provide [discharge instructions] in Spanish. All of that’s going to be incorporated.”

More documenting is a way to bridge communication too, along with setting company-wide goals on care transitions, said Chubb.

“It’s something that you can’t lose sight of, in the same way as health literacy [is important]. Are we following what we said we’re going to follow? We need to make sure there’s not a disconnect within the clinical team,” said Chubb.

An MDS coordinator, for example, may not be communicating as effectively as they could be with the clinical team, she said. It’s up to leadership to bridge these gaps and make sure all team members are communicating.

Ease of access, common tech across care settings

Communication across care settings isn’t just from person to person either, Chubb said, emphasizing ease of access between software platforms which can in turn improve overall communication during an admission or discharge.

“Sometimes those software providers also make it very difficult for a hospital to connect to them on the back end. I think that [EHR] ease of use for the hospital is going to be imperative,” said Chubb.

Stuercke said having medical record systems that don’t “talk to each other” in 2025 is “crazy,” but that having a close relationship with hospital staff can help where software platforms are lacking.

In one example, Stuercke said a patient was sent over with a tracheostomy that wasn’t detailed on EHR, resulting in the patient being ping-ponged back and forth between the hospital and nursing home. A quick phone call to the hospital staff resolved confusion, but further conversations on how to avoid such a situation can help future transition issues.

“It’s not about my nurses, not about their nurses. It’s about this patient who either came back and forth really quickly, or is now in a situation that is not the best to meet their needs,” said Stuercke. “We have to develop that relationship with our hospitals.”

A partnership with community hospitals means more safety in the admission and discharge process, with less issues slipping through the cracks, said Stuercke.