It takes a team

As a nurse providing bedside care, have you ever wondered why certain patients are difficult to discharge? Could it be issues with "transitional care?"

This story was published in the Fall 2022 issue of The Washington Nurse.

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Transitional care encompasses a broad range of services and environments designed to promote the safe and timely passage of patients between levels of healthcare and across care settings.

Gaps can occur in this process, including poor communication, incomplete transfer of health information, a lack of essential services in a community, inadequate discharge education, complicated financial reimbursements, regulatory constraints, and literacy, language, or cultural barriers.

Unfortunately, gaps in planning transitional care can result in readmissions and adverse events. A 2022 review by the Agency for Healthcare Research and Quality (AHRQ) of patients being discharged directly to home or community-based care revealed that “approximately one in five hospitalized patients are readmitted within 30 days and a third of patients are readmitted in 90 days.”

About half of older adults transitioning from the hospital to community settings were affected by at least one medical error, and 20% were affected by one or more adverse events. Low socioeconomic status predicted a particularly substantial risk for poor outcomes, such as medication errors, injuries, and higher hospital readmission rates.

Discharges to skilled nursing facilities fared somewhat better but were more costly according to a 2019 JAMA article. “Among Medicare beneficiaries eligible for post-acute care at home or in a skilled nursing facility, discharge to home with home healthcare was associated with higher rates of readmission, no detectable differences in mortality or functional outcomes, and lower Medicare payments.”

So, what can you do? Nursing care is instrumental to your patient’s well-being in the facility. The trust that you have developed with family and caregivers makes you an important part of a safe care-transitions plan! Since discharge planning begins at admission, here is how to help:

  • Use good communication skills, and include family caregivers. For a quick review, see the American Association of Critical Nurses blog about shifting the focus to families. A good resource with talking points about COVID in various languages is the COVID Ready Communication Playbook by VitalTalk.org.
  • Mobilization: Mobilization is a key action that RNs can take to prevent patient deconditioning. Hospitalized patients, who were independent prior to admission, lose function at a staggering rate while in the hospital. Without mobilization and conditioning, patients may be unable to return home and require a skilled nursing facility stay.
  • Reinforce the discharge plan of care. Refer to the AHRQ guide, “Taking care of myself: A guide for when I leave the hospital”, or other facility-provided materials.
  • Know your facility’s care transitions staff. Keeping up with the regulations, community resources, and payment processes is daunting. The facility staff are the experts in transitions work, sometimes based on The Centers for Medicare and Medicaid Services (CMS) requirements or recommendations by AHRQ.
    Provide assistance by knowing some of the information they will need and coordinate efforts. (See the Washington State Hospital Association’s two-page “Warm Handover Guide”).
  • Review regulations or legal materials (such as a power of attorney, guardianship, portable medical orders, etc.) for healthcare decisions that might be barriers to transferring out of the facility. (For example, a minimum stay of three days is required for a skilled nursing facility admission covered by fee-for-service Medicare.)
    Also, it’s important for families to know medical insurance does not pay for custodial care. Custodial care is paid out of pocket, by long-term care insurance or by Medicaid. In many instances, patients with resources have to spend down their resources on their own care to qualify for Medicaid.

It takes a team to develop and reinforce a safe care-transitions plan: You, the patient, family caregivers, and your care-transitions professionals.

WSNA continues to pursue opportunities for safe staffing in healthcare facilities. We know, and research confirms, that inadequate nurse staffing leads to medical errors, poorer patient outcomes, nurse burnout, and injuries to nurses.

Our Nursing Care Quality Assurance Commission submitted the Long-term Care Workforce Development Final Report in June 2021, and this important document helped advise the Washington State Governors Budget, which now includes provisions for addressing the nursing shortage and the crisis in long-term care.

As nurses, we need to stay informed and continue the important work of advocating for our patients and ourselves. Take a step, and learn more about care transitions.

Karla Hall, BSW, BSN, RN, CCM, contributed to this article.

Joni Hensley is a retired public health nurse certified as an infection-control professional through the Association for Professionals in Infection Control. Hensley worked at the Washington State Department of Health with a team of nurses dealing with healthcare-acquired infections during the pandemic. She also participated in the NOVAVAX vaccine trial while employed at the University of Washington. Hensley was honored to work with the American Nursing Association on the latest edition of the “Public Health Nursing Scope of Practice.” Some of her work on disease outbreaks has been published in CDC MMWRs. Currently, she is serving as a faith community nurse in a rural community and volunteering with a nonprofit equine therapy group that works with disadvantaged youth and local tribes.

Dr. Albert Munanga has served in various professional senior leadership roles in health facilities caring for seniors, and he remains active in gerontological care. Dr. Munanga is currently chief clinical officer for Serengeti Home Health based in Renton. He is also clinical faculty at the University of Washington’s School of Biobehavioral Nursing and Health Care Informatics. Munanga is a widely cited clinical scholar who has published in several medical journals. In 2021, he released “The New Rules of Engagement: Infection Prevention & Control in Group Living Settings: A Guide for Healthcare Professionals and the Concerned Public” as a call to arms in the battle against communicable diseases. He is chair of the WSNA Long-Term Care Committee and has been active in state and national long-term care quality committees over the years.


McElroy V. et al., Post-acute transitional services: Safety in home-based care programs (2022), AHRQ, Patient Safety Network.

Werner, et al., Patient outcomes after hospital discharge to home with home healthcare vs to a skilled nursing facility, JAMA Intern Med; May 2019, 179 (5):617-623

Nelson, J., Communicating with families: Shifting the focus (2020), American Association of Critical Care Nurses blog.

COVID Ready Communication Playbook, Vital Talk at vitaltalk.org.

Taking care of myself: A guide for when I leave the hospital, AHRQ.

Washington State Hospital Association, Partnership for Patients, WARM Handover Guide.

Medicare coverage of skilled nurses facility care.

Washington State Governor’s Budget (2022).

Additional reference

Naylor, Mary PhD, RN, FAAN; Keating, Stacen A. PhD, RN; Transitional Care. American Journal of Nursing: September (2008), Volume 108, Issue 9, pages 58-63.