Transitions From Hospitals to Skilled Nursing Facilities for Persons With Dementia: A Challenging Convergence of Patient and System-Level Needs
Open accessAbstract
Purpose of the Study: To describe skilled nursing facility (SNF) nurses’ perspectives on the experiences and needs of persons with dementia (PwD) during hospital-to-SNF transitions and to identify factors related to the quality of these transitions. Design and Methods: Grounded dimensional analysis study using individual and focus group interviews with nurses (N = 40) from 11 SNFs. Results: Hospital-to-SNF transitions were largely described as distressing for PwD and their caregivers and dominated by dementia-related behavioral symptoms that were perceived as being purposely under-communicated by hospital personnel in discharge communications. SNF nurses described PwD as having unique transitional care needs, which primarily involved needing additional discharge preplanning to enable preparation of a tailored behavioral/social care plan and physical environment prior to transfer. SNF nurses identified inaccurate/limited hospital discharge communication regarding behavioral symptoms, short discharge timeframes, and limited nursing control over SNF admission decisions as factors that contributed to poorer-quality transitions producing increased risk for resident harm, rehospitalization, and negative resident/caregiver experiences. Engaged caregivers throughout the transition and the presence of high-quality discharge communication were identified as factors that improved the quality of transitions for PwD. Implications: Findings from this study provide important insight into factors that may influence transitional care quality during this highly vulnerable transition. Additional research is needed to explore the association between these factors and transitional care outcomes such as rehospitalization and caregiver stress. Future work should also explore strategies to improve inter-setting communication and care coordination for PwD exhibiting challenging behavioral symptoms.
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Hospital pressures to react to the increase in admissions meant that health and social care professionals felt additional pressure to discharge because the bed was required.
“Hospital pressures to react to the increase in admissions meant that health and social care professionals felt additional pressure to discharge because the bed was required [33, 34].”
From Stakeholder perspectives of care for people living with dementia moving from hospital to care facilities in the community: a systematic review (2019) · cites this paper as [33]
Cites
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“The concept of tailoring transitional care activities to individual resident backgrounds/preferences is not widely reflected in existing evidence-based transitional care programs, which rely heavily on standardized approaches (Coleman, Parry, Chalmers, & Min, 2006; Feltner et al., 2014; Kind et al., 2012; LaMantia, Sc…”
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Evidence-Based Interventions for Transitions in Care for Individuals Living With Dementia
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Self-citationDeterminants of hospital readmissions in older people with dementia: a narrative review
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“In cases where communication on NPS and care management strategies is present, SNF providers have cited that discharge communication is often inaccurate, conflicting or missing key details.(24) Of particular note, SNF providers report challenges admitting persons with dementia requiring antipsychotics to manage NPS an…”
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Analysis of discharge documentation for older adults living with dementia: A cohort study
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- Authors
- Gilmore-Bykovskyi, A. L., Roberts, T. J., King, B. J., Kennelty, K. A., & Kind, A. J. H.
- Affiliations
- Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Memorial Veterans Hospital , Madison, Wisconsin
- University of Wisconsin–Madison (US)
- Venue
- The Gerontologist
- Publisher
- Oxford University Press (OUP)
- Published
- 2016-05-12
- Volume
- 57
- Issue
- 5
- Pages
- 867-879
- ISSN
- 0016-9013 (ISSN-L)
- 1758-5341
- PMC
- PMC5634404
- OpenAlex
- W2388511395
- Cited by
- 56
- References
- 7
- Citations by year
- 2026: 3 · 2025: 1 · 2024: 5 · 2023: 5 · 2022: 6 · 2021: 10 · 2020: 8 · 2019: 7 · 2018: 6 · 2017: 5
- FWCI
- 9.95
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- The Gerontologist (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute on Aging (K23AG034551)
- American Federation for Aging Research
- John A. Hartford Foundation
- Atlantic Philanthropies
- Starr Foundation
- Topics
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Keywords
- dementia, care transitions, discharge communication, behavioral symptoms, discharge planning, caregiver involvement, hospital readmission
- MeSH terms
- Transitional Care, Aged, Attitude of Health Personnel, Communication, Dementia, Hospitalization, Hospitals, Humans, Nurses, Patient Transfer, Skilled Nursing Facilities, Focus Groups, Needs Assessment
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