Table 1 Connect-Home: transitional care structure

EHR tool

Transition Plan of Care Template

Before randomization, an EHR template will be installed in the SNF EHR system. It will contain free text fields in 6 key care domains that SNF staff and home visit RNs will use to record transition goals and deliver the two-step intervention [34].

Toolkit

Connect-Home Toolkit

All staff will be given 36-page workbook that includes the 2-step intervention protocol (Table 2), checklists and cue sheets, and the intervention schedule.

Staff Training

Site Leadership Training (1 h)

Principal investigator (PI) will train 1–2 SNF project leaders. Training content: Connect-Home protocol and study procedures. Teaching strategy: Presentation, the Connect-Home Toolkit, and teach-back

Staff Training (4 h)

In each SNF, the PI will train social workers, nurses (RN, LPN, NP), rehabilitation therapists (PT, OT, ST, COTA, PTA) and the Home Health RN. Training content: (a) Patient and caregiver key care needs. (b) Protocols for using the two-step intervention to address key care needs. (c) Using the EHR template to individualize patients’ Transition Plan of Care. (d) Advance care planning. (e) Integrating SNF-based and home-based care (e.g., clinical hand-offs from SNF to Connect-Home Activation RN, home health care, and follow-up medical providers). Teaching strategy: Presentation, review of the Connect-Home Toolkit, and teach-back.

Home Health Care RN (1.5 h).

The PI provides additional training for the Connect-Home Activation RN for each SNF (Table 2, below). Training content: Strategies for implementing transition plans of care, home safety screening, responding to medical needs, and handing-off care to home health nurses (when applicable). Teaching strategy: One-to-one instruction and return demonstration.

New Staff Training (1–2 h, as needed):

The PI trains replacement staff to use the Connect-Home protocols.