Short-stay nursing home rehabilitation patients: Transitional care problems pose research challenges

Journal of the American Geriatrics Society

Volumn 56, Issue 10, 2008, Pages 1940-1945

  Quinn, Charlene C ^a,e   Port, Cynthia L ^a   Zimmerman, Sheryl ^b   Gruber Baldini, Ann L ^a   Kasper, Judith D ^c   Fleshner, Irene ^d   Yody, Barbara ^d   Loome, John ^d   Magaziner, Jay ^a  

^a UNIVERSITY OF MARYLAND SCHOOL OF MEDICINE   (United States)

^b UNIVERSITY OF NORTH CAROLINA   (United States)

^c JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH   (United States)

^d Genesis HealthCare Corporation   (United States)

^e SCHOOL OF MEDICINE   (United States)

Author keywords

Care transition; Nursing home; Rehabilitation; Research

Indexed keywords

COMORBIDITY; DECISION MAKING; DEPRESSION; GERIATRIC CARE; HEALTH CARE; HEALTH CARE POLICY; HEALTH CARE QUALITY; HEALTH PRACTITIONER; HOSPITAL DISCHARGE; HOSPITALIZATION; HUMAN; MEDICAL PRACTICE; MEDICAL RESEARCH; NURSING HOME; PHYSICIAN; REVIEW;

AGED; CONTINUITY OF PATIENT CARE; DEPRESSION; HEALTH SERVICES RESEARCH; HUMANS; LENGTH OF STAY; NURSING HOMES; QUALITY ASSURANCE, HEALTH CARE; REHABILITATION;

EID: 53149096206     PISSN: 00028614     EISSN: 15325415     Source Type: Journal    
DOI: 10.1111/j.1532-5415.2008.01852.x     Document Type: Review

References (30)

1. Wells JL, Seabrook JA, Stolee P et al. State of the art in geriatric rehabilitation. Part II: Clinical challenges. Arch Phys Med Rehabil 2003 84 : 898 903.
2. Gilbody SM, Whitty PM, Grimshaw JM et al. Improving the detection and management of depression in primary care. Qual Saf Health Care 2003 12 : 149 155.
3. Coleman EA, Boult C. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc 2003 51 : 556 557.
4. Boockvar K, Fishman E, Kyriacou CK et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med 2004 164 : 545 550.
5. Coleman EA, Fox PD. Managing patient care transitions: A report of the HMO Care Management Workgroup. Healthplan 2004 45 : 36 39.
6. Parry C, Coleman EA, Smith JD et al. The care transitions intervention: A patient-centered approach to ensuring effective transfers between sites of geriatric care. Home Health Care Serv Q 2003 22 : 1 17.
7. van Walraven C, Seth R, Austin PC et al. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med 2002 17 : 186 192.
8. Coleman EA, Smith JD, Frank JC et al. Development and testing of a measure designed to assess the quality of care transitions. Int J Integr Care 2002 2 : e02. Published online June 1, 2002. Available at
9. Weaver FM, Perloff L, Waters T. Patients' and caregivers' transition from hospital to home: Needs and recommendations. Home Health Care Serv Q 1998 17 : 27 48.
10. Coleman EA, Min SJ, Chomiak A et al. Posthospital care transitions: Patterns, complications, and risk identification. Health Serv Res 2004 39 : 1449 1465.
11. Moore C, Wisnivesky J, Williams S et al. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 2003 18 : 646 651.
12. Murtaugh CM, Litke A. Transitions through postacute and long-term care settings: Patterns of use and outcomes for a national cohort of elders. Med Care 2002 40 : 227 236.
13. Gehlbach SH, Avrunin JS, Puleo E. Trends in hospital care for hip fractures. Osteoporos Int 2007 18 : 585 591.
14. Centers for Medicare & Medicaid Services, Office of Information Services. Data from the Medicare Decision Support Access Facility: Office of Research, Development, and Information [on-line]. Available at Accessed January 15, 2008.
15. Port CL. Informal caregiver involvement and illness detection among cognitively impaired nursing home residents. J Gerontol A Biol Sci Med Sci 2006 61A : 970 974.
16. National Citizens' Coalition for Nursing Home Reform (NCCNHR), Family Involvement in Nursing Home Care, Consumer Fact Sheet No.3, March 2004 on-line]. Available at : Accessed April 30, 2008
17. Moore C, McGinn T, Halm E. Tying up loose ends: Discharging patients with unresolved medical issues. Arch Intern Med 2007 167 : 1305 1311.
18. Boyle VL, Roychoudhury C, Beniak R et al. Recognition and management of depression in skilled-nursing and long-term care settings: Evolving targets for quality improvement. Am J Geriatr Psychiatry 2004 12 : 288 295.
19. Lenze EJ, Munin MC, Dew MA et al. Adverse effects of depression and cognitive impairment on rehabilitation participation and recovery from hip fracture. Int J Geriatr Psychiatry 2004 19 : 472 478.
20. Kripalani S, Jackson AT, Schnipper JL et al. Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. J Hosp Med 2007 2 : 314 323.
21. Katz PR, Karuza J, Kolassa J et al. Medical practice with nursing home residents: Results from the National Physician Professional Activities Census. J Am Geriatr Soc 1997 45 : 911 917.
22. Newcomer R, Kang T, Graham C. Outcomes in a nursing home transition case-management program targeting new admissions. Gerontologist 2006 46 : 385 390.
23. Coleman EA, Smith JD, Frank JC et al. Preparing patients and caregivers to participate in care delivered across settings: The Care Transitions Intervention. J Am Geriatr Soc 2004 52 : 1817 1825.
24. Naylor MD, Brooten D, Campbell R et al. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA 1999 281 : 613 620.
25. Coleman EA. Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc 2003 51 : 549 555.
26. Halasyamani L, Kripalani S, Coleman E et al. Transition of care for hospitalized elderly patients - development of a discharge checklist for hospitalists. J Hosp Med 2006 1 : 354 360.
27. Schwartz AN, Vogel ME. Nursing home staff and residents families' role expectations. Gerontologist 1990 30 : 49 53.
28. Ryan AA, Scullion HF. Family and staff perceptions of the role of families in nursing homes. J Adv Nurs 2000 32 : 626 634.
29. Port CL, Zimmerman S, Williams CS et al. Families filling the gap: Comparing family involvement for assisted living and nursing home residents with dementia. Gerontologist 2005 45 (Spec No 1(1 : 87 95.
30. Williams MA, Oberst MT, Bjorklund BC. Early outcomes after hip fracture among women discharged home and to nursing homes. Res Nurs Health 1994 17 : 175 183.