Nursing Facility Transitions of Care Take Center Stage at Quality Learning Collaborative

Transitions of care, whether between hospitals and skilled nursing facilities or between nursing facilities and the community, can present challenges and lead to disruptions in care. The second quarter of programming for the Pennsylvania Long-Term Learning Network for Nursing Facilities focused on strategies for addressing some of these challenges. The quarterly Learning Collaborative webinar, on June 22, provided an opportunity for nursing facilities from across the Commonwealth to come together to hear best practices for improving transitions of care. Nearly 200 participants joined the webinar, which addressed all six of the 2023 nursing facility quality incentive program goals as outlined by the Department of Human Services.

Larry Appel, MD, SFHM, medical director at the Department of Human Services Office of Long-Term Living (OLTL), provided an update on work being done at the state level, including a nursing facility listening tour conducted by OLTL's new deputy secretary, Juliet Marsala, MS, MBA, CRC. Dr. Appel expressed excitement for the growth of the Long-Term Care Learning Network and the quality of the programming. As noted in the results of the first quarter survey, satisfaction with the Learning Network webinars remained extremely high, with an increase in the number of facilities initiating quality improvement projects based on content from the webinars.

Four nursing facilities presented best practices around transitions of care. Amie Hull, DNP, CRNP, supervisor of advance practice providers at UPMC Senior Communities, shared about her facility's POLST policy, including the POLST review process and staff education and training initiatives. She stressed the importance of continuous quality improvement to ensure meaningful POLST conversations with the appropriate individuals. In an engaging panel discussion moderated by Tiffany Bloom, BSW, senior program manager at UPMC Community HealthChoices, Susan Stemmerich, service coordinator at UPMC Community HealthChoices, and Sue Ann Priemer, director of social services at QLS Markleysburg, discussed strategies they use to foster a positive working relationship between the nursing facility service coordinators and nursing facility staff, which ultimately enhances the care provided to residents.

Rollin Wright, MD, MS, MPH, associate professor of medicine in the Division of Geriatric Medicine at Penn State Health, shared about the innovative Bridge to Home program, which helps to address challenges with transitions to home from post-acute care for patients who need more assistance than can be provided by family caregivers. The program benefits both patients and nursing facilities by improving transitions and reducing costs.

The benefits of implementing palliative care for those experiencing serious illness are well known, but the use of palliative care in nursing facilities remains limited. Richard Hoffmaster, MD, director of palliative medicine at UPMC St. Margaret's and medical director at Presbyterian SeniorCare – Longwood at Oakmont, described models of palliative care in the nursing facility and the need to focus on what the nursing home can provide for residents to help to reduce the need for transfers to the hospital. He stressed the importance of working with the interprofessional team and having a champion at your facility.

Nancy Zionts described the evolution of the Revisiting Teaching Nursing Home pilot into a new phase with the Teaching Nursing Home Collaborative. The pilot established a foundation for relationships between schools of nursing and nursing homes, with codesign as an embedded philosophy and demonstrated the value of bidirectional sharing of information. The next phase of the initiative aims to capitalize on the successes of the pilot and expand to involve more partners, and Zionts invited all nursing facilities from across the state to join the effort.

The webinar concluded with association updates. Clinical nurse consultant Brian Stever, BSN, RN, RAC-CT, vice president of the board for the Pennsylvania Association of Nurse Assessment Coordinators, presented on updates to the Minimum Data Set and the implications for long-term care facilities. Sophie Campbell, MSN, RN, CRRN, RAC-CT, CNDLTC, Pennsylvania Association of Directors of Nursing Administration (PADONA) executive director of programs and services, discussed updates on regulations affecting nursing facilities, which are effective July 1, 2023. This includes staffing ratio requirements and per patient day staffing levels. She shared about upcoming educational offerings from PADONA and legal considerations for nursing facilities in the wake of the Supreme Court's upholding of the right of residents and their survivors to sue publicly held nursing homes in federal court over key care provisions. She also shared that PADONA board chair Candace McMullen spoke to the general assembly on the current situation in long-term care and urged them to take action to address the workforce challenges.

The third quarter of programming kicks off on July 6 and will focus on a series of sessions aimed at enhancing skills to manage complex conditions.