Challenges related to transitioning from hospital to temporary care at a skilled nursing facility: a descriptive study.

Purpose: With decreasing number of hospital beds, more citizens are discharged to temporary care at skilled nursing facilities, requiring increasingly complex care in a non-hospital setting. We mapped challenges related to the transition of citizens from hospital to temporary care at a skilled nursing facility in relation to medication management, responsibility of medical treatment, and communication.

Methods: Descriptive study of citizens discharged from Odense University Hospital to temporary care from May 2022 to March 2023.

Results: We included 209 citizens (53% women, median age 81 years). Most citizens (97%; n = 109/112) had their medication changed during hospital admission. Citizens used a median of eight medications, including risk medications (96%, n = 108). Medication-related challenges occurred for 37% (n = 77) of citizens and most often concerned missing alignment of medication records. Half of citizens (47%, n = 99) moved into temporary care with all medication needed for further dispensing. Nurses conducted in median three telephone calls (interquartile range [IQR 1-4]) and sent in median two correspondences (IQR 1-3) per citizen within the first 5 days. Nurses most often called the hospital physician (41% of telephone calls, n = 265/643) and sent correspondences to the general practitioner (55% of correspondences, n = 257/469). For 31% (n = 29/95) of citizens requiring action from nursing staff, this could have been avoided if the nurses had had access to the discharge letter.

Conclusion: We identified several challenges related to the transition of patients from hospital to temporary care, most often related to medication. A third of actions related to medication management were considered avoidable with improved practices around communication.