Helping Patients and Their Caregivers Transition to Care at Home

By Nancy LaMontagne from the Carolina Nursing Magazine

After acute hospital care, one in five older adults transfers to a nursing home for three to four weeks of rehabilitation and nursing care before returning home. These frail older adults experience very high risk for poor outcomes at home, and are frequently rehospitalized for recurring medical problems. SON Assistant Professor Mark Toles, PhD, RN, and his colleagues developed Connect-Home —a group of innovative tools and strategies to support older adults and their caregivers during transitions from the nursing home to home.

A signature trait of Connect-Home is the design to prepare older adults and their caregivers to manage the patient’s serious illnesses. For example, patients must learn new ways to safely move around the house, to care for healing wounds and fractures, and to work with a large health care team. Owing to the complexity of care for multiple illnesses, family members must also learn to participate. For example, both the patient and their caregivers must understand advance care plans, administering medications, scheduled home health care visits, and key questions to explore with the patient’s physicians.

Connect-Home provides tools and training for the staff in nursing homes, who have the ultimate responsibility to help the patient and caregiver prepare for continuing care at home. For example, Connect-Home introduces tools in electronic health records systems that nurses, rehabilitation therapists and social workers use to deliver care. As Toles explained, “We have tried to stay as close to the actual nursing homes as possible and learn anything we can from people who are involved in giving and receiving this care.” He added, “With Connect-Home, we can provide the right tools in nursing homes for staff to use and help patients recover at home.”

Connect-Home is an evolving model of care. First designed in 2014, Connect-Home is currently used in five nursing homes in North Carolina, and others in three additional states. The early evidence of intervention impact is promising. Patients and their caregivers who were supported with Connect-Home resources report having the skills and support to successfully manage the transition to home. Staff working in nursing homes report the intervention is helpful and should be used in the future. Toles added, “Caregivers sometimes have a stressful job. We have made progress but still have a ways to go to be able to help them learn ways to support their loved ones over time and handle any hardships as they come along.”

Understanding the problem

In 2014, Toles and his colleagues published a study that looked at health outcomes of 55,000 older adults in North and South Carolina who went home after a nursing home stay. The study described the risk older adults confront — within 90 days of returning home, more than 50 percent of these older adults were readmitted to the hospital, visited an emergency department or had passed away. “These findings were a strong signal to us that care at home was a serious challenge, and that we needed to find ways to reduce the high risk for complications,” said Toles.

As the research team sought partners to improve outcomes for patients, they collaborated with partners in a local nursing home chain, Lutheran Services Carolinas, to implement Connect-Home in Hickory, Salisbury and Winston-Salem. “We would never have figured out ways to improve patient outcomes without our partners at Lutheran Services Carolinas,” said Toles. “We had our model of care and the skills to measure outcomes, but they had the nursing homes and were already caring for patients and their families every day.”

A sustainable design

Toles and his team recently showed that nursing homes that adopted Connect-Home successfully sustained it over time and were able to do so with their own resources. “This was a critical step as sustaining Connect-Home is where the greatest impact will emerge,” Toles said. For example, the team is now working with Lutheran Services of America to bring Connect-Home to more North Carolina nursing homes and others in Maryland, Michigan and New Jersey.

“We are striving to improve the quality of life for older adults and caregivers,” said Toles. “We’re making progress, taking our first steps to care for older adults with serious illnesses at home.”

Research conducted by Toles’ team has been supported by The John A. Hartford Foundation, the National Institutes of Health, Lutheran Services of America, The Harry and Jeanette Weinberg Foundation, and the UNC Chapel Hill School of Nursing.