Table 2 Connect-Home: transitional care processes (time estimates based on 20-day SNF stay)

Step 1.

Transitional care in the SNF

Set goals for home-based care (45 min)

Consulting with the patient/caregiver, SNF staff use the EHR template to identify goals to address the 6 key care needs of patients and their caregivers.

 ● Nurses create goals for treatments and responses to symptoms or other health changes

 ● Rehabilitation therapists create goals for mobility, transfers, and self-care.

 ● Social worker creates goals for caregiver support, follow-up care, and discharge disposition.

2–17

Meet to plan the patient’s transition to home-based care (30 min)

In dialog with the patient/caregiver, the treating nurse, social worker, and therapists will develop a plan for home-based care, targeting 6 key care needs.

 ● Nurses focus on medications, advance care planning and symptom management.

 ● All staff help the patient and caregiver describe their needs for continuing care at home.

 ● Social worker reviews Transition Plan of Care and the Connect-Home Activation Visit.

5–10

Prepare the patient and caregiver for home-based care (2.5 h)

1. Teach skills and plans for home-based care, targeting 6 key care needs.

 ● Nurses teach symptom management (e.g., pain), clarify advance care planning preferences, and reconcile medication orders.

 ● Rehabilitation Therapists teach skills for function and safety at home.

 ● Social worker schedules and explains appointments, home-based care, and cost.

2. Initiate hand-off to home-based care (over the last 1–2 days before discharge)

 ● SNF staff send medical records and copies of any advance care planning documents to the patient’s physician and the Connect-Home Activation RN.

 ● Nurses: (a) reconcile medications, (b) provide supplies and medications, and (c) re-teach the written Transition Plan of Care and medication list.

6–20

Step 2.

Transitional care in the patient’s home

Implement the Transition Plan of Care at home (2 h)

Connect-Home Activation Nurse visits the patient and caregiver at home to:

 ● Reconcile medications on the discharge medication list and in the home,

 ● Help family implement new care routines, addressing 6 key care needs,

 ● Conduct a brief home safety and falls prevention screen,

 ● Coordinate care with follow-up clinicians and home health care nurses, when applicable.

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