Saskatoon Health Region (SK)

  • Gaylene Molnar, Program Manager, Geriatric Evaluation and Management Services and Rehabilitation Outpatients, Saskatoon Health Region, Saskatoon, Saskatchewan

Older Adults Transitioning from Hospital to Home: Bridging the Gap

Transition from hospital to home can be problematic for older adults. Multiple co-morbidities, numerous medications to manage medical conditions and changes in physiological function increase their complexity. Acute hospital admission is often associated with significant decline in physical function at discharge, making a return to independent living difficult. These factors along with gaps in discharge planning, poor coordination of care and insufficient communication contribute to the potential for adverse events, hospital readmission and frequent visits to the emergency department.

Review of the literature revealed that interventions that combine discharge planning with ongoing discharge support including in home follow up had the greatest effect on reducing post discharge problems in older patients. The focus of this pilot project was to implement a standard set of transition support interventions. These activities were carried out by transition nurses, an additional role specifically assigned to support older adults identified as high risk of readmission using the LACE screen. Early results indicate a positive influence on readmission rates, emergency room visits, and improved patient, family and care provider experience for a small sample within SHR.

Transition nurses also identified multiple system factors contributing to transition problems for all patients, not just older adults. Variation occurred in the amount of planning and coordination with community partners, in the identification of discharge needs and patient teaching. Communication of critical information did not always occur between care providers, patients and their families. Standards are needed to ensure the needed interventions occur in a consistent time-frame for all transitions.
The question remains as to whether the additional role of transition nurse is needed or if existing nursing roles have the time and ability to provide the standard interventions in a consistent time-frame. A feasibility study must be completed as staff workload was identified to be a factor contributing to limited discharge planning and communication issues.

The Saskatoon Health Region is well positioned to focus on quality improvement, placing the patient and family at the center of all we do with the province wide implementation of LEAN methodologies. This pilot project is the first step towards improving the transition process for older adults. Further work is needed to clarify roles and assign responsibility for standard transition work.