Introduction
A smooth transition from the hospital to the nursing home setting is essential because older patients are likely to struggle with self-care and follow recommendations for recovery. The elderly have higher risks of making medication errors, may experience issues with their mobility, as well as be overall unaware of their treatment plan. Because of these issues, the risks of rehospitalization increase as older patients cannot implement treatment on their own.
Example of a Transition of Care
The example of transition of care chosen for further exploration is concerned with the transition of care from the hospital to the nursing home setting for patients that came to receive healthcare for various conditions. The patients that need help transitioning from the hospital to the nursing home setting are typically seniors who may struggle with immobility, cognitive issues, and other health limitations that may not allow them to be effective. The conditions for which patients are treated at hospitals include but are not limited to chronic disabling issues, problems with feedings themselves, and other conditions that are treated without planned hospitalization and require immediate action from healthcare providers.
The systems thinking approach (ST) to care transition for patients from hospitals to nursing homes can be of benefit because it encourages nurses to develop critical leadership skills to address the challenges associated with highly complex systems of healthcare service. The assistance of professionals at nursing homes is necessary because they can guarantee care continuity and ensure that the treatment plan established by the healthcare team at the hospital is followed to facilitate recovery or well-being maintenance. However, in the case of the transition, issues arise in terms of transfer orders and information, risks to patient safety during transitions, and the lack of communication between professionals working at hospitals and nursing homes.
Key Stakeholders
The first and the most essential group of stakeholders involved in the transitioning of care from hospitals to nursing homes are front-line nurses who directly work with patients and implement the prescribed methods of treatment formulated by doctors. When researchers interviewed these nurses, they indicated that complicated transitions from the hospital to the nursing home setting were quite common (Glette et al., 2018). Moreover, the nurses struggled with giving details on flawless transitions, which suggests that there are always some problems associated with the transitioning of care.
When it comes to nursing home front-line workers, many of such nurses felt that they lacked information regarding what occurred with their patients when they were at hospitals. There were gaps in data about patients’ medical status, and the problem was not with paperwork but rather with the abundance of unnecessary details that had no connection to recommendations for transitioning. Besides, the transfer information had errors and went in conflict with what the patients were told to do before being transferred to the nursing home. Essentially, as the key stakeholders expected to guarantee good care continuity, nurses were challenged by having limited insight into the functional and cognitive status of their patients. Better collaboration and improved communication between nurses at hospitals and nursing homes are expected to improve the quality of transitions between the two settings.
The second important stakeholder group is represented by the family members of older adults who often accompany them to hospitals and help get accommodated at nursing homes. Family members may experience challenges when it comes to the transitioning of care because they are not well-informed about the health status of their relatives. In case of a care transition, family members are expected to ask questions regarding the care for older patients before leaving the hospital and make sure that the information they gather is communicated to nurses at nursing homes. Importantly, since nurses at nursing homes often struggle with gaps in information, family members should inform them about things that occurred while their older relative was at the hospital. It is necessary to report any tests, procedures, changes in previously-prescribed medication, new diet recommendations, the need for physical therapy, and other information. Thus, family members are stakeholders who can help bridge gaps in information about older patients’ health and recommendations for care transition at nursing homes. Family members can become active participants in their relatives’ care and have a beneficial impact on improving the process of transfer from one place of care to another.
Both task-oriented and relationship-oriented leadership strategies can be beneficial for facilitating effective care transitions of care from the hospital setting to the nursing home environment. With the help of task-oriented leadership, the leader will plan relevant activities, clarify the roles within the stakeholder groups, set objectives, and continue the monitoring and performance of processes (Sfantou et al., 2017). Through relationship-oriented leadership, those involved in the care transition will be encouraged to support one another, recognize each other’s roles and efforts, as well as develop strong and trusting relationships.
Application of Systems Thinking
When transitioning older patients from the hospital to the nursing home setting, the systems thinking approach entails considering the pervasive interdependencies that exist between actors at different systems levels. The ST approach is expected to be applied at all levels of the transitioning process, including the continuing of patients’, their families, and nurses’ education, the evaluation of their knowledge and skills, as well as addressing patient safety and quality of care across the steps of transitioning.
For nurse leaders implementing the ST approach, they can use consistent evaluations to assess the level of knowledge and practice for identifying the gaps in care transition that needs improving. ST can be applied for educating nurses and patients’ family members about the appropriate practices they should implement to facilitate a framework of care consistency across different levels of care (Phillips et al., 2019). For enhancing the learner improvement feedback, a leader will establish a standardized rubric for determining stakeholders’ success, create clear definitions for performance measurement criteria, develop a rating scale, and define a standard of excellence. The assessment criteria can be aligned with the care transition goals and expectations, with processes being implemented throughout the transitioning to the nursing home setting.
The ST approach is possible to align with the IHI Quadruple Aim (QA) framework as it could help facilitate an improved understanding of the roles and responsibilities expected from relevant stakeholders. Because the care transition process is concerned with older patients, the fourth aim is the pre-discharge continuous fall risk screening and assessment and providing documentation to nursing homes regarding such risks. Specifically, the QA framework will include the implementation of a fall risk assessment tool, such as the TUG test, several days before the discharge from the hospital to identify the risk dynamics before the transition is complete.
Another strategy entails providing detailed fall risk reports in the transitioning documentation. Because nursing home front-line workers often do not get the fullness of information about their patients, a fall risk report included in the documentation can be helpful for selecting adequate equipment, such as active and passive assistive and protective devices, and recommendations for handling fall prevention. The two recommended strategies align with the QA principles as they aim to reduce care costs by preventing older patients’ readmissions to hospitals due to falls and emphasizing the importance of all-rounded care for individuals who require more attention from nurses (Feeley, 2017). Overall, the implementation of the IHI Quadruple Aim approach when transitioning the care for older patients from the hospital to the nursing home setting is expected to reduce excessive workloads in both settings, with the strategies emphasizing improved communication between the care process stakeholders.
Improvement Through Systems Thinking
Systems thinking is expected to help provide improved care that is focused on the patient and foster problem-solving. In the transitioning of older patients, the health care system, the provider system, and patient systems are expected to collaborate to create a well-rounded and adaptive framework that will facilitate effective collaboration between different participants of the care process. When implementing the systems thinking approach within the chosen example of care transition, the participants of the process will be encouraged to understand the bigger picture and observe how the elements of the system, ranging from pre-discharge risk assessment to patients’ adjustment at nursing homes. Moreover, coming to quick conclusions without considering the fullness of information about patients should be avoided because of the unintended consequences.
Therefore, the improvement of care transition from the hospital to the nursing setting through ST means that no step or process is viewed in isolation and should be used together with interdependent concepts for understanding complex work processes. Most of the healthcare issues and solutions are a part of a system and thus will be resolved through a system (McNab et al., 2019). For instance, improving the fall risk assessment before hospital discharge will not improve the general system performance unless the assessments are accessed and used appropriately at nursing homes. Essentially, the hospital system interacts with the nursing home system, and the exchange of information between them should be structured in a manner that enhances the care process and not limits it. Moreover, it is notable that there are external factors that influence each system and lead to some changes, which is why cohesion between the hospital and nursing home settings is necessary.
Conclusion
To conclude, the process of transitioning older patients from a hospital to a nursing home is complex and multi-dimensional as it requires increased collaboration between the stakeholders. Nurses that have been involved in the process of transitioning mention that they struggle with gaps in reports and lack relevant information on the recommendations for care for the patients. Thus, with the help of a systems approach, it will become easier to treat the transition of care process as an interaction between several systems, with the enhancement of processes influencing the system overall. It is more cost-effective to implement ST in combination with Quadruple Aim strategies because of the focus on enhancing the fullness of information that can be transferred between systems to improve patient care and outcomes during and after the transition.
References
Feeley, D. (2017). The Triple Aim or the Quadruple Aim? Four points to help set your strategy. Institute for Healthcare Improvement. Web.
Glette, M. K., Røise, O., Kringeland, T., Churruca, K., Braithwaite, J., & Wiig, S. (2018). Nursing home leaders’ and nurses’ experiences of resources, staffing and competence levels and the relation to hospital readmissions – A case study. BMC Health Services Research, 18(955). Web.
McNab, D., McKay, J., Shorrock, S., Luty, S., & Bowie, P. (2019). Development and application of ‘systems thinking’ principles for quality improvement. BMJ Open Quality, 9(1). Web.
Sfantou, D. F., Laliotis, A., Patelarou, A. E., Sifaki-Pistolla, D., Matalliotakis, M., & Patelarou, E. (2017). Importance of leadership style towards quality-of-care measures in healthcare settings: A systematic review. Healthcare (Basel, Switzerland), 5(4), 73. Web.