Testing the Efficacy of Transitional Care of Patients and Caregivers during Transitions from Skilled Nursing Facilities to Home

Principal Investigator: Mark Toles, PhD, RN, FAAN
Funded by: National Institute of Nursing Research, National Institutes of Health

Each year, 1.6 million older adults receive care in a hospital, followed by a short stay in a nursing home. After the transition back home, these patients and their caregivers often lack the knowledge, skill and support required to manage the older adults’ serious illnesses. It is no surprise that about half of these individuals return to the hospital or die within three months.

Mark Toles’ research suggests that more intentional care surrounding the transition to home-based care saves lives. Toles is conducting a randomized and controlled trial of his successfully piloted Connect-Home intervention in nursing homes and home care offices across North Carolina. Connect-Home includes creating an individualized transition care plan and implementing the plan at home. This intervention has the potential to improve the lives of seriously ill older adults and reduce the burdens on caregivers.