Abstract
Multiple chronic illnesses are common among adults over the age of 65 years. The presence of these comorbidities combined with advancing age can produce functional decline that decreases the ability for self-care. This disability may be especially pronounced following hospitalization, and necessitate post-acute care in skilled nursing facilities (SNF). Nurses, then, become managers of chronic illness during recovery until elders or their families can resume their roles in chronic illness management. The overall objective of this pilot/feasibility study is to examine transfer of care for chronically ill older adults admitted to skilled nursing facilities following hospitalization. Specifically, the qualitative descriptive study aims to: 1) describe the work of licensed nurses in SNFs when hospitalized older adults are transferred to their care; and 2) identify areas in the hospital-SNF transfer process that are amenable to nursing intervention to minimize negative consequences associated with care complexity and changes in nursing care settings and providers. A convenience sample of approximately 10 licensed nursing staff, consisting of RNs and licensed practical nurses serving in direct care roles who participate in accepting patients in hospital transfers will be recruited from four nursing homes in the greater New Haven, CT area. Data collection methods include unstructured informal interviews, naturalistic observation, semi-structured interviews and document analysis. Data will be analyzed using qualitative content analysis from a grounded theory approach, consisting of constant comparison and a two-phased coding process to generate themes. Findings will be used to develop and test interventions to improve outcomes for older adults transferred from hospitals to SNFs and that reduce the burden of reconstructing fragmented care plans for SNF nurses who have fewer clinical and human resources to draw upon.
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