An “F” for Quality

Huge numbers of older persons transition from hospitals to the nursing home.  Often, an older hospitalized patient needs skilled nursing care before they are ready to return home.  In other cases, a nursing home patient who needed hospitalization is returning to the nursing home.  Older patients and their families certainly hope that great communication between the hospital and nursing home would assure a seamless transition in care.

But a rather stunning study in the Journal of the American Geriatrics Society suggests the quality of communication between the hospital and the nursing home is horrendous.  The study was led by researchers from the University of Wisconsin, including nurse researcher, Dr. Barbara King and Geriatrician Dr. Amy Kind.

The authors conducted interviews and focus groups with 27 front line nurses in skilled nursing facilities.  These nurses noted that very difficult transitions were the norm.  Sadly, when asked to give the details of a good transition, none of the nurses were able to think of an example.

Most of the nurses felt that they were left clueless about what happened to the their patient in the hospital.  They lacked essential details about their patient’s clinical status.  The problem was not the lack of paper work that accompanied the patient.  In fact, nurses often received reams of paper work, often over 80 pages.  The problem is that the paper work was generally full of meaningless gibberish such as surgical flow sheets that told little about what was actually going on.

Often the transfer information had errors, conflicted with what the facility was told before the transfer, and lacked accurate information about medications.

Essentially, SNF nurses found themselves asked to care for patients with little sense of what actually happened in the hospital, and little insight into the functional and cognitive status of their patients.  These episodes of poor communication led to a number of adverse consequences:

  • Patients were put at risk for medication errors. In particular, patients were often left in pain while nurses tried to find a physician to write the orders for opiods that were not included with the transfer
  • Efforts to mobilize patients were delayed while nurses tried to figure out what level of mobility was safe, as the transfer information did not indicate what level of ambulation was safe.
  • Time nurses should have been able to spend caring for patients was instead spent on trying to piece together the records and tracking down primary care providers and hospital providers to learn details about the hospitalization and the medicine regimen.
  • The nurses felt their credibiity and the credibility of the nursing home were undermined with patients and families as the chaotic process made them look bad.  Patients and families assumed something was wrong with the nursing home.
King and Kind point to the need for serious efforts to improve the quality of transitions between the hospital and nursing home.  The type of communication problems noted in this article certainly must have a negative impact on patient outcomes.


Ken Covinsky, MD is a professor of geriatrics and clinical researcher at the UCSF School of Medicine. He blogs at GeriPal, where this post first appeared.

13 replies »

  1. A seamless transition of care involves genuine caring and concern on the part of all parties. These subtle tasks, which take time and can easily be “swept under the rug” can avoid typical methods of scrutiny. On the other hand, we all know when the end result is not good, when the desert tastes bad. We encourage patients, nurses, doctors, and other hospital staff to place their comments and opinions on http://www.RateHospitals.com

  2. After seeing my grandparents go through vicious cycles between being at home, in the hospital, and in nursing homes/manor care, I can totally relate to this. It always seemed like the caregivers had no idea what to do or no previous knowledge of my grandparent’s medical history. It was a lot of starting over and mistakes were made that made their recovery very difficult. There is a major communication flaw. Nurses and doctors need to learn how to communicate much more effectively with caregivers before patients and transferred over.

    My parents are almost at the age where I need to look into senior home care for them. After seeing all of the chaos between my grandparents and their nursing homes, I kind of want to avoid it. I’m leaning towards NJ Senior Care. They really seem to care about their patients and if I can do at-home care it might make things easier. I think they have better communication systems in tack as well.

  3. Care transitions leave many of us providers feeling helpless in certain cases, and hoping that failure or morbidity does not arise from the transition we took part in. In hospital to SNF/outside transfers, this is one area where Telemedicine could dramatically improve the comfort around care of patients. Further, such enhanced communication is paired with EHR improvements, checklists and interoperability (which admittedly is a ways off in some cases), care could be dramatically improved and errors could be profoundly reduced.

  4. I just did a hospital dc to a local nh for a short term rehab. The discharge summary contained a letter and very carefully worded and detailed instructions and orders for the nursing home. Patient dc from hospital at 9am. Arrives at 1:30pm (nh is 1 mile from hospital). I get a call from the nursing home to “verify orders”! A lot of the problem is the nursing staff in nursing homes can’t read, have extremely poor judgement and many shouldn’t even be nurses at all. The low standards, coupled with incredibly stupid regulations and policies for nursing homes are definitively contributors to the “f” grade!

  5. Many thanks for all of the great comments–which collectively point to key aspects of the underlying problem and possible solutions. The comments lead me to think of two issues that need to be addressed:

    Discontinuity–Perhaps one of the problems with continuity across transitions is that there is so much discontinuity within settings. It seems that during many hospitalizations, no one really knows the patient anymore. The doctors and nurses are constantly changing. How can we assure information flow from the hospital to the nursing home if the information flow is so poor within the hospital?

    Reams of paper–One of the big problems with hospital care is that there is little attention and documentation of key geriatric issues like functional impairment and cognitive impairment. These are crucial issues for the providers in the nursing home. But it is hard to transmit this information if it was never properly assessed in the first place. This may be part of why SNF providers feel they get reams of information, but not the information they need to take care of the patient.

  6. Repeatedly studies show that mortality approaches 25% with each transfer cycle from nursing facility to hospital and back. The deterioration in mental status and satisfaction are not even studied very well yet.

    Every healthcare organization in the loop is billing and getting paid, but the patients are dying. In some states, the empty nursing facility bed must be paid for while the patient is admitted. The reimbursement incentives are misaligned and prevent innovation.

    So, there are few conditions treated in the nursing facility. There are few mobile clinics for nursing facilities so far. There is no real training on ‘avoidable transfers’… Innovations in Care Transition will help, but how do we prevent this chasm of poor quality? We should prevent transfers by changing components of the care delivery systems.

  7. Sobering post but certainly rings true.

    Re picking up the phone, as Dr. Leng suggests; a phone call can be very helpful, but that’s assuming the discharging physician knows the patient, and can easily reach the next doc. But now with all the shifts and cross-covering among doctors, seems patients are often discharged by someone who doesn’t really know them.

    Also, I like written documentation because then it’s clear what was said, and can be shared with the family and other providers. But it’s true that much written documentation is boilerplate, or template text, or otherwise unhelpful. Or buried in the pointless workflow sheets.

  8. Paperwork is the problem. Take the paperwork away. Pick up the phone. The doctor most responsible for the patient while hospitalized should actually physically talk to the receiving institution, at the very least the nurse receiving the patient but ideally to the medical director. Nurse should call nurse.

    What do you pay more attention to: an evite, an actual invitation, or a call? Reverse order. Make it personal, make it patient specific. It doesn’t take that long.

  9. So I guess there’s really not a problem except that people can’t find the right document and/or someone didn’t include some “LTC-relevant” information that should only take a few minutes of one person’s time to include it in that document. Perhaps it takes “walking in the other person’s shoes” – either the professional at the other end or the patient and family – to understand what’s involved. I’ve been surprised when I’ve heard physicians speak about the care they or a family member received that didn’t match what they thought routinely happened, and often took on a piece of the problem as their mission. I’ve been surprised because it appears that they don’t know what their patients and patients’ families experience. I hope that continues to change so that these problems can be solved. That only happens when they’re taken seriously.

  10. We do in fact write discharge summaries that contain all the information the above poster suggested. (They are required by the facilities for transfer.) One problem may be that its thrown into the pile of papers sent over. In the hospital we experience the same miscommunication when patients come to us from nursing homes or different hospitals. Part of the reason we face this information overload challenge is the people who initiate transfers are not medically savvy enough to discriminate what does and does not need to be sent. They hit the “print everything” button and throw everything into a folder.

    A simple email from provider to provider to send the discharge summary for every transfer would eliminate this problem by eliminating all the junk.

  11. Ideally, if a physician knew that their patient was going to be admitted to a nursing home following hospital discharge, they would include a summary of information relevant to the continued care of the patient in an assisted living context. This would include prescription information, a summary of procedures conducted and/or treatments proffered in the hospital, and predictions about future complications. They should probably also include whatever personal information they can offer about the patient (likes, dislikes, personality traits, etc.) I assume this would take all of five minutes and save far more time than that on the assisted living side.

  12. I think at least part of the problem is the practice of conducting a completely new “assessment” at every transition. The person moves from one place to another – shouldn’t the patient’s status be pretty close to the same after the trip across town or across the street? I think these artificial boundaries make it difficult to have continuity – have an ongoing assessment and care plan that gets updated along the way. That would also save a great deal of time – and stick to what’s important, what the patient wants and what the patient needs (hopefully all pretty close to the same thing). Update the status and plan continuously, no matter where the patient is located. And include the patient and family members – ask MaryAnne Sterling how it could work!


  13. The same thing happens with patients transitioning from acute care to home health and SNF to home health.

    Why is this so difficult?