Background and Importance With decreasing number of hospital beds, more patients are discharged from hospitals to temporary care at skilled nursing facilities requiring handling of more complex and frail citizens in a non-hospital setting.
Aim and Objectives We aimed to systematically map challenges related to the transition of patients from hospital to temporary care at a skilled nursing facility in relation to (i) medication management, (ii) responsibility of the medical treatment, and (iii) communication.
Material and Methods This descriptive study included medical or surgical patients admitted to hospital and discharged to temporary care at a skilled nursing facility from May-December 2022.
Results Preliminary results are available for 67 patients (52% women and mean age 77 years). A nurse from the skilled nursing facility used in average a ten minute phone call to coordinate with a nurse from the hospital before discharge. In 100% (n=67) of the patients the medication to the first day sent from the hospital was used, even if there in 30% (20 of 67) was problems due to missing update of the Shared Medication Record, changed strength, missing or unidentified medication, or other discrepancies. Only 58% (n=39) received all needed medication during the first day needed for further medication dispensing. The nurses made in average three (range 0-10) calls and sent three electronically correspondences per patient about medication within the first five days. In 36 of 60 (60%) patients did the discrepancy between the discharge notice from the nurses and the discharge letter, not result in any further action from the skilled nursing facility. However in 38% (n=9) of the 24 patient records that required extra action from the skilled nursing facility, the action could have been avoided if the nurses from the skilled nursing facility had had the discharge letter. Full results for an expected 200 patients will be available and presented at the EAHP conference.
Conclusion and Relevance We identified challenges related to, in particular, lack of needed medication and communication. A third of the actions related to medication management were considered avoidable with improved practices around communication.
Conflict of Interest Corporate sponsored research or other substantive relationships: The study was funded by the public health research fund of the Region of Southern Denmark.
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