Date of Graduation

Summer 8-13-2021

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

First Advisor

Tara O'Connor

Abstract

Section I: Abstract

Problem: Skilled nursing facility (SNF) patients are vulnerable, aging, and have complex medical histories. Readmissions from an SNF impact healthcare costs and hospital resources and indicate poorly coordinated transitions home. Patients discharging from SNFs are at risk for higher social determinants of health (SDOH) disparities, such as limited caregiver support, transportation, housing insecurity, and food access. These SDOH risks can significantly increase an SNF patient's risk for hospital readmissions. Assessing and addressing SNF patients' social needs to reduce 30-day post-SNF readmissions can improve health outcomes and positively impact healthcare costs and a patient's financial liabilities.

Context: Frailty, chronic medical illnesses, and limited social support are significant predictors for SNF readmissions. Standardized assessment of SDOH for SNF patients upon admission from the hospital can identify deficits in caregiver resources, nutrition, mobility, socialization, transportation, and financial resources. Early evaluation of SDOH care gaps allows planning for individualized interventions and resources to allow patients and primary caregivers to be successful in the community and to reduce unplanned 30-day post-SNF readmissions.

Interventions: The interventions included a quality improvement project to improve psychosocial assessments for patients discharged from the hospital to an SNF; modification and implementation of an evidence-based psychosocial assessment, with complementary interventions as the primary goal; and staff education to raise awareness and to plan effective interventions to reduce readmissions focused on improving patient outcomes.

Measures: A set of metrics was created. The outcome measure concentrated on increasing the number of patients who had a psychosocial assessment completed after being admitted to an SNF, which documented both the evaluation and the intervention to any identified care gaps. The process measures were developing and training the department SNF registered nurses to utilize the psychosocial frail bundle assessment tool to plan and secure interventions. Staff satisfaction surveys and rounding interviews were the balancing measure to determine job satisfaction, defined as the staff's time, workload, and compliance with the new frail bundle workflow.

Results: Project metrics demonstrated a gradual increase between January 18 and June 30, 2021, from 0% to 94% of SNF patients who received a psychosocial frail bundle assessment. SDOH interventions, planned or secured, also increased from 0% to 88% during the same time span.

Conclusions: This project aimed to modify, implement, and utilize a psychosocial assessment tool to identify appropriate interventions for patients with SDOH care gaps admitted to an SNF. The successful integration of this assessment resulted in up to 94% of patients admitted to an SNF having a psychosocial evaluation and 88% with at least one intervention documented in their electronic medical record.

Keywords: Readmissions, health-related social needs, social determinant of health assessment, skilled nursing facility

Comments

Section I: Abstract

Problem: Skilled nursing facility (SNF) patients are vulnerable, aging, and have complex medical histories. Readmissions from an SNF impact healthcare costs and hospital resources and indicate poorly coordinated transitions home. Patients discharging from SNFs are at risk for higher social determinants of health (SDOH) disparities, such as limited caregiver support, transportation, housing insecurity, and food access. These SDOH risks can significantly increase an SNF patient's risk for hospital readmissions. Assessing and addressing SNF patients' social needs to reduce 30-day post-SNF readmissions can improve health outcomes and positively impact healthcare costs and a patient's financial liabilities.

Context: Frailty, chronic medical illnesses, and limited social support are significant predictors for SNF readmissions. Standardized assessment of SDOH for SNF patients upon admission from the hospital can identify deficits in caregiver resources, nutrition, mobility, socialization, transportation, and financial resources. Early evaluation of SDOH care gaps allows planning for individualized interventions and resources to allow patients and primary caregivers to be successful in the community and to reduce unplanned 30-day post-SNF readmissions.

Interventions: The interventions included a quality improvement project to improve psychosocial assessments for patients discharged from the hospital to an SNF; modification and implementation of an evidence-based psychosocial assessment, with complementary interventions as the primary goal; and staff education to raise awareness and to plan effective interventions to reduce readmissions focused on improving patient outcomes.

Measures: A set of metrics was created. The outcome measure concentrated on increasing the number of patients who had a psychosocial assessment completed after being admitted to an SNF, which documented both the evaluation and the intervention to any identified care gaps. The process measures were developing and training the department SNF registered nurses to utilize the psychosocial frail bundle assessment tool to plan and secure interventions. Staff satisfaction surveys and rounding interviews were the balancing measure to determine job satisfaction, defined as the staff's time, workload, and compliance with the new frail bundle workflow.

Results: Project metrics demonstrated a gradual increase between January 18 and June 30, 2021, from 0% to 94% of SNF patients who received a psychosocial frail bundle assessment. SDOH interventions, planned or secured, also increased from 0% to 88% during the same time span.

Conclusions: This project aimed to modify, implement, and utilize a psychosocial assessment tool to identify appropriate interventions for patients with SDOH care gaps admitted to an SNF. The successful integration of this assessment resulted in up to 94% of patients admitted to an SNF having a psychosocial evaluation and 88% with at least one intervention documented in their electronic medical record.

Keywords: Readmissions, health-related social needs, social determinant of health assessment, skilled nursing facility

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